Associations between KIR/KIR-ligand genotypes and clinical outcome for patients with advanced solid tumors receiving BEMPEG plus nivolumab combination therapy in the PIVOT-02 trial

Bempegaldesleukin (BEMPEG), a CD122-preferential IL2 pathway agonist, has been shown to induce proliferation and activation of NK cells. NK activation is dependent on the balance of inhibitory and excitatory signals transmitted by NK receptors, including Fc-gamma receptors (FCγRs) and killer immunoglobulin-like receptors (KIRs) along with their KIR-ligands. The repertoire of KIRs/KIR-ligands an individual inherits and the single-nucleotide polymorphisms (SNPs) of FCγRs can influence NK function and affect responses to immunotherapies. In this retrospective analysis of the single-arm PIVOT-02 trial, 200 patients with advanced solid tumors were genotyped for KIR/KIR-ligand gene status and FCγR SNP status and evaluated for associations with clinical outcome. Patients with inhibitory KIR2DL2 and its ligand (HLA-C1) observed significantly greater tumor shrinkage (TS, median change -13.0 vs. 0%) and increased PFS (5.5 vs. 3.3 months) and a trend toward improved OR (31.2 vs. 19.5%) compared to patients with the complementary genotype. Furthermore, patients with KIR2DL2 and its ligand together with inhibitory KIR3DL1 and its ligand (HLA-Bw4) had improved OR (36.5 vs. 19.6%), greater TS (median change -16.1 vs. 0%), and a trend toward prolonged PFS (8.4 vs. 3.6 months) as compared to patients with the complementary genotype. FCγR polymorphisms did not influence OR/PFS/TS.These data show that clinical response to BEMPEG plus nivolumab treatment in the PIVOT-02 trial may be associated with the repertoire of KIR/KIR-ligands an individual inherits. Further investigation and validation of these results may enable KIR/KIR-ligand genotyping to be utilized prospectively for identifying patients likely to benefit from certain cancer immunotherapy regimens.

Association of Body Mass Index With the Safety Profile of Nivolumab With or Without Ipilimumab

Importance

Increased survival with immune checkpoint inhibitors has been reported for patients with obesity vs a normal body mass index (BMI). However, the association of obesity with the safety of immune checkpoint inhibitors warrants study.

Objective

To investigate associations between BMI and immune-related adverse events (irAEs) among patients with advanced cancers treated with nivolumab monotherapy and nivolumab plus ipilimumab combination therapy.

Design, Setting, and Participants

This study was a retrospective pooled analysis of 3772 patients from 14 multicenter CheckMate clinical trials across 8 tumor types. Patients with advanced cancers received nivolumab, 3 mg/kg (n = 2746); nivolumab, 3 mg/kg, plus ipilimumab, 1 mg/kg (n = 713); or nivolumab, 1 mg/kg, plus ipilimumab, 3 mg/kg (n = 313). Baseline BMI was categorized as normal weight or underweight (<25), overweight (25 to <30), or obese (≥30) according to World Health Organization criteria. The studies began patient enrollment between February 9, 2012, and May 21, 2015, and patients were followed up to database lock on May 1, 2019. Data analysis was conducted from May 1 to September 1, 2019.

Interventions

Nivolumab, 3 mg/kg; nivolumab, 3 mg/kg, plus ipilimumab, 1 mg/kg; and nivolumab, 1 mg/kg, plus ipilimumab, 3 mg/kg.

Main Outcomes and Measures

Odds ratios (ORs) and 95% CIs for incidence of any-grade and grade 3 or 4 irAEs were calculated for patients with obesity vs normal weight or underweight BMI in the overall cohort and in subgroups based on patient and tumor characteristics. Analyses for nivolumab plus ipilimumab cohorts were exploratory.

Results

A total of 3772 patients were included, 2600 were male (69%), and median age was 61 years (range, 18-90 years). For patients receiving monotherapy with nivolumab, 3 mg/kg (n = 2746), the incidence of any-grade irAEs was higher in patients with obesity (n = 543) vs those with normal weight or underweight BMI (n = 1266; OR, 1.71; 95% CI, 1.38-2.11). Incidence of grade 3 or 4 irAEs did not differ between patients with obesity and those with normal weight or underweight BMI (OR, 1.21; 95% CI, 0.92-1.61). Risk of any-grade and grade 3 or 4 irAEs appeared consistent with that in the overall population across all subgroups evaluated except for a higher likelihood of grade 3 or 4 irAEs among female patients with obesity vs normal weight or underweight BMI (OR, 1.73; 95% CI, 1.07-2.79). For patients receiving nivolumab plus ipilimumab, the incidence of irAEs appeared consistent across BMI categories.

Conclusions and Relevance

Obesity appeared to be associated with an increased incidence of any-grade irAEs among patients treated with nivolumab monotherapy and with grade 3 or 4 irAEs among female patients only. These findings may inform the monitoring of patients at high risk of developing irAEs.

Abstract 3112: Metabolic hallmarks of rare renal cell carcinoma patient-derived xenograft models

Renal medullary carcinoma (RMC) and fumarate hydratase (FH)-deficient renal cell carcinoma (RCC) are rare but highly aggressive malignancies that are often refractory to the therapies used for the more common RCCs. FH-deficient RCC most often occurs in individuals with hereditary leiomyomatosis and renal cell carcinoma syndrome (HLRCC) and is characterized by loss of FH activity, a key metabolic enzyme. Bevacizumab plus erlotinib (B+E) is a preferred first-line therapy for FH-deficient RCC. RMC is characterized by loss of SMARCB1, which is involved in ATP-dependent chromatin remodeling. Platinum-based chemotherapy consisting of either cisplatin or carboplatin plus paclitaxel is the preferred first-line therapy for RMC. We developed patient-derived xenograft (PDX) models of tumors exposed to the commonly used first-line therapies to allow functional characterization of the metabolic hallmarks of treatment-experienced RMC and FH-deficient RCC. Methods: Resected tumor tissue was immediately implanted into NSG male and female mice. After tumor engraftment, animals were euthanized, and the tumor tissue implanted into another set of NSG mice. PDX tissues were confirmed to be genetically identical to the original patient tissue by short tandem repeat analysis. Histology was confirmed to be identical between original patient tumor and PDX by a trained clinical pathologist. Four tumors from each PDX model and four normal human kidney tissue samples were analyzed using reverse phase protein array (RPPA). Expression of proteins shown to be highly expressed by RPPA were further validated by Western blots. Results: We successfully generated one PDX model for RMC and one for FH-deficient RCC, respectively. The RMC model was generated from a 28-year old male with sickle cell trait, who had previously received cisplatin plus paclitaxel followed carboplatin plus paclitaxel. His lesion was characterized as ypT3apN1pMx and histology was consistent with RMC. The FH-deficient RCC model was generated from a 24-year-old female with HLRCC, who had been previously treated with B+E. Her lesion was characterized as pT3apN1pM1 and histology consistent with FH-deficient RCC. Germline testing revealed a R233H pathogenic mutation in the FH gene. RPPA revealed higher expression of hexokinase II (10x HLRCC, 16x RMC), lactate dehydrogenase A (27x HLRCC, 17x RMC), and glutaminase (4x HLRCC) in PDX tissue compared to normal kidney tissue. Western blots confirmed higher expression of glutaminase 1 in both HLRCC and RMC compared to normal kidney. Furthermore, we observed substantially higher hypoxia inducible factor 2α (HIF2α) protein expression in PDX tissue from FH-deficient RCC compared to RMC PDX tumors and normal kidney. Conclusions: Our study revealed distinct metabolic features in PDX models of FH-deficient RCC following treatment with B+E, and of platinum-experienced RMC, these differences may confer targetable vulnerabilities.

Citation Format: Manuel Ozambela, Alberto Pieretti, Graciela M. Nogueras Gonzalez, Tapati Maity, Lei Wang, Carolyn De La Cerda, Breanna Alonzo, Luis Segarra, Angelita Alaniz, Priya Rao, Nizar Tannir, Jose A. Karam, Christopher G. Wood, Pavlos Msaouel, Niki M. Zacharias. Metabolic hallmarks of rare renal cell carcinoma patient-derived xenograft models [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 3112.

241 Immune checkpoint blockade (ICB) in brain metastases (BM) from advanced small cell urothelial cancer (aSCUC)

Background

The risk of BMs in patients with aSCUC, having bulky tumors or non-cerebral metastasis at presentation, is high. We aimed to investigate the impact of ICB on the clinical outcomes of patients with aSCUC and BMs.

Methods

Patients with aSCUC treated at MD Anderson Cancer Center between April 1992 and July 2019 were included if they had brain imaging and developed BMs during their disease course. Median overall survival (mOS) was calculated from diagnosis of BMs until death and if alive was censored at last contact. Hazard ratios (HR) and 95% confidence intervals (95% CI) were calculated using logrank test.

Results

Among 216 patients with aSCUC, 111 underwent computed tomography or magnetic resonance imaging of the brain, and 34 (31%) were diagnosed with BMs. Baseline characteristics are included (table 1). At initial diagnosis of SCUC, clinical stage was cT1/x,cT2,≥cT3/4 or N+ (15%,44%,41%, respectively). Twenty-three (67.6%) underwent prior cystectomy, 16 (47%) had received neoadjuvant chemotherapy (NACT). Pathologic response at cystectomy after NACT was pT0/Tis,pT1,pT2,≥pT3b/4 or N+ (31%,6%,13%,50%, respectively). Those who did not undergo cystectomy (11, 32%) were either due to progression, declining surgery, or had de novo metastatic disease (27%,18%,55%, respectively). Regarding localized BM management, 9 (26%) patients received whole brain radiation therapy, 7 (21%) received stereotactic radiosurgery (SRS) and 7 (21%) received both. Median follow-up from BM diagnosis was 31.7 months. Five patients elected to pursue comfort care only, with mOS 0.7 months. Twenty-three patients received systemic therapy, including 11 (48%) who received ICB during any line of therapy. Majority of patients received ICB as single agent anti-PD(L)1; one patient received a doublet of anti-PD1+anti-CTLA4. Patients who were treated with ICB had numerically longer mOS as compared to those who solely received chemotherapy (10.7 months vs. 9.0 months, HR=0.47,95%CI=0.18–1.25,P=0.15), (figure 1). mOS decreased in patients with 1 vs 2 vs 3 vs ≥5 BMs (18.8,8.7,7.5 and 4.7 months, respectively, P=0.02), (figure 2). Furthermore, mOS improved with combination of ICB+SRS vs chemotherapy+SRS vs ICB without SRS vs chemotherapy without SRS (unreached,20.9,7.5,8.4, respectively, P=0.03) (figure 3).

Abstract 241 Table 1

Baseline characteristics of patients

Abstract 241 Figure 1

Survival based on systemic therapy approach among all SCUC patients with brain metastases (n=34)

Abstract 241 Figure 2

Survival based on number of brain metastases among all 34 patients

Abstract 241 Figure 3

Survival based on systemic + local therapy approach among SCUC patients with brain metastases with brain metastases who received both (n=23)

Conclusions

In this first analysis to describe outcomes of patients with aSCUC and BMs with the inclusion of ICB treatment and despite the small sample size, we see a trend toward increased survival with fewer BMs, especially with combined ICB and SRS. Although challenging due to its rarity, future prospective trials evaluating the synergy between ICB and SRS in SCUC should be considered.

Ethics Approval

This retrospective study received approval from the MD Anderson Cancer Center institutional review board

Durable responses in patients with genitourinary cancers following immune checkpoint therapy rechallenge after moderate-to-severe immune-related adverse events

Background

Immune checkpoint therapy (ICT) prolongs survival in subsets of patients with cancer but can also trigger immune-related adverse events (irAEs) requiring treatment discontinuation. Recent studies have investigated safety of ICT rechallenge after irAEs, and evidence suggests that rechallenge may be associated with improved antitumor responses. However, data are limited on response duration after ICT rechallenge, particularly after severe irAEs.

Objective

To evaluate safety and efficacy of ICT rechallenge after moderate-to-severe irAEs in patients with renal cell carcinoma (RCC), urothelial carcinoma (UC), and prostate cancer.

Methods

In this retrospective cohort study, medical records from September 25, 2013, to June 1, 2020, for patients with genitourinary (GU) cancers at MD Anderson Cancer Center who were rechallenged with the same or different ICT following irAEs were reviewed. Demographics, ICT exposure, irAEs (grade and treatment), ICT discontinuation or rechallenge, rates of subsequent irAEs (new or recurrent) and antitumor activity (objective response rates and response duration) were reviewed.

Results

Sixty-one patients with RCC, UC, and prostate cancer were rechallenged with ICT after experiencing 105 total irAEs. Objective response rates after rechallenge, that is, upgrade in response, were 14% in RCC (4/28), 21% in UC (3/14), and 0% in prostate cancer. All seven patients who achieved upgrade in response had initial grade 2 or 3 irAEs. Responses were durable among these seven patients, with median radiographic progression-free survival not reached (range: 3.7–66.4 months) as of the March 8, 2021, data cut-off (median follow-up 40.9 months (95% CI 35.3 to 46.5)). All achieved complete response except one patient who was lost to follow-up. The rate of subsequent grade 3 or 4 irAEs after rechallenge was 30%, with no fatal irAEs. The rate of recrudescence of the same irAE was 26% (16/61). 54% of patients received corticosteroids (33/61), and 21% received targeted immunosuppression (13/61) for the initial irAEs.

Conclusions and relevance

ICT rechallenge after moderate-to-severe irAEs was associated with deep and durable responses in a subset of patients with RCC and UC, with acceptable safety and no fatal events. Strategies to enable ICT resumption after moderate-to-severe irAEs, such targeted immunosuppression, warrant further study.

Abstract CT109: Phase I study of mTORC1-2 inhibitor sapanisertib (TAK-228) in combination with carboplatin plus paclitaxelin patients with advanced solid malignancies and mTOR pathway alterations

Introduction: Pre-clinical models show that the addition of the mTORC1/2 inhibitor sapanisertib (TAK-228) restores sensitivity to platinum chemotherapy and dramatically enhances paclitaxel-induced cancer cell killing. Carboplatin plus paclitaxel is an established therapy in a variety of cancers including non-small cell lung cancer, ovarian cancer and others. This phase 1 study (NCT03430882) assessed the safety and tolerability of sapanisertib in combination with carboplatin plus paclitaxel in patients with advanced solid malignancies enriched with mTOR pathway alterations.

Methods: Eligible patients, enriched for mTOR pathway aberrant tumors by CLIA-certified next-generation sequencing, received increasing sapanisertib doses on day 2-4 of each week at 2mg (Dose level 1; 4 patients), 3mg (Dose level 2; 4 patients) and 4mg (Dose level 3; 4 patients) combined with carboplatin (AUC 5) intravenously every 3 weeks on day 1 of each cycle plus paclitaxel 40mg/m2 (Dose levels 1-3), 60mg/m2 (Dose level 4; 7 patients) on day 1, 8, and 15 of each cycle.

Results: Among the patients enrolled, males were 8/19 (42%), median age was 59 (range: 33-74). Of the 12 patients treated with Dose levels 1-3, 11 patients were evaluable for dose-limiting toxicities (DLTs) and no DLTs were observed. Seven patients were treated in Dose level 4 and among the 6 patients that were evaluable for DLTs, 1 patient had a DLT. Genomic alterations included PI3K/PTEN in 11/19 (58%), NF1 in 2/19 (10.5%), NF2 in 2/19 (10.5%), TSC1 in 1/19 (5%), TSC2 in 1/19 (5%), and EWSR1-POU5F1 fusion in 1/19 (5%). Of 17 patients evaluable for response, disease control rate (CR+PR+SD) was 76.4 % including 2 patients who achieved partial response. Responders were a patient with sarcomatoid renal cell carcinoma harboring EWSR1-POU5F1 fusion, who remains on therapy for more than 18 months. In addition, a patient with castrate resistant prostate cancer who progressed on cabazitaxel but harbors PTEN loss and remained on therapy for 7.3 months. There were no unanticipated toxicities. Grade 3-4 treatment-related adverse events included anemia (4/19; 21%), neutropenia (4/19; 21%), thrombocytopenia (2/19; 10.5%), and transaminitis (1/19; 5%).

Conclusion: Sapanisertib in combination with carboplatin plus paclitaxel demonstrated a manageable safety profile, with preliminary antitumor activity observed in patients with advanced malignancies harboring mTOR pathway alterations.

Citation Format: Omar Alhalabi, Aung Naing, Roman Groisberg, Andrew Hahn, Shizhen Zhang, Samantha C. Berkey, Apostolia M. Tsimberidou, Jordi Rodon, Timothy A. Yap, Shubham Pant, Amishi Y. Shah, Amado Zurita-Saavedra, Nizar Tannir, Funda Meric-Bernstam, Vivek Subbiah. Phase I study of mTORC1-2 inhibitor sapanisertib (TAK-228) in combination with carboplatin plus paclitaxelin patients with advanced solid malignancies and mTOR pathway alterations [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 CT109.

Phase 2 study of pembrolizumab in patients with advanced rare cancers

Background

Patients with advanced rare cancers have poor prognosis and few treatment options. As immunotherapy is effective across multiple cancer types, we aimed to assess pembrolizumab (programmed cell death 1 (PD-1) inhibitor) in patients with advanced rare cancers.

Methods

In this open-label, phase 2 trial, patients with advanced rare cancers whose tumors had progressed on standard therapies, if available, within the previous 6 months were enrolled in nine tumor-specific cohorts and a 10th cohort for other rare histologies. Pembrolizumab 200 mg was administered intravenously every 21 days. The primary endpoint was non-progression rate (NPR) at 27 weeks; secondary endpoints were safety and tolerability, objective response rate (ORR), and clinical benefit rate (CBR).

Results

A total of 127 patients treated between August 15, 2016 and July 27, 2018 were included in this analysis. At the time of data cut-off, the NPR at 27 weeks was 28% (95% CI, 19% to 37%). A confirmed objective response (OR) was seen in 15 of 110 (14%) evaluable patients (complete response in one and partial response in 14). CBR, defined as the percentage of patients with an OR or stable disease ≥4 months, was 38% (n=42). Treatment was ongoing in 11 of 15 patients with OR at last follow-up. In the cohort with squamous cell carcinoma (SCC) of the skin, the NPR at 27 weeks was 36%, ORR 31%, and CBR 38%. In patients with adrenocortical carcinoma (ACC), NPR at 27 weeks was 31%, ORR 15%, and CBR 54%. In the patients with carcinoma of unknown primary (CUP), NPR at 27 weeks was 33%, ORR 23%, and CBR 54%. In the paraganglioma–pheochromocytoma cohort, NPR at 27 weeks was 43%, ORR 0%, and CBR 75%. Treatment-related adverse events (TRAEs) occurred in 66 of 127 (52%) patients, and 12 (9%) had grade ≥3 TRAEs. The most common TRAEs were fatigue (n=25) and rash (n=17). There were six deaths, all of which were unrelated to the study drug.

Conclusions

The favorable toxicity profile and antitumor activity seen in patients with SCC of skin, ACC, CUP, and paraganglioma–pheochromocytoma supports further evaluation of pembrolizumab in this patient population.

Trial registration number

NCT02721732

A Phase I Trial of the MET/ALK/ROS1 Inhibitor Crizotinib Combined with the VEGF Inhibitor Pazopanib in Patients with Advanced Solid Malignancies

BACKGROUND

Crizotinib inhibits ALK, MET and ROS1 tyrosine kinases but the development of resistance to monotherapy is an issue. The anti-angiogenic properties of pazopanib could overcome crizotinib drug resistance. Additionally, the anti-angiogenic properties of crizotinib could augment the clinical efficacy of pazopanib.

METHODS

We evaluated the safety and responses in patients with advanced solid tumors treated with crizotinib and pazopanib.

RESULTS

Eighty-two patients (median age 53 years, range 18-78 years) were enrolled. The median number of prior systemic therapies was 3 (range, 0-8). We were able to dose escalate to dose level 8 (crizotinib 250 mg twice daily and pazopanib 800 mg daily) with no MTD identified. Grade 3 or 4 toxicities were seen in 32% of patients with the highest prevalence being fatigue (n=9, 11%), diarrhea (n=6, 7%), vomiting (n=3, 4%), anemia (n=2, 2%) and ALT increased (n=2, 2%). Of the 82 patients, 61 (74%) had measurable disease by RECISTv1.1 and reached first restaging (6 weeks). Partial response (PR) was observed in 6/61 (10%) patients, and stable disease (SD) lasting ≥6 months was observed in 10/61 patients (16%) (total = 16/61 (26%) of patients with SD ≥6 months/PR).

CONCLUSION

Dose level 6 (crizotinib 200 mg twice daily and pazopanib 600 mg daily) was the most tolerable dosing of the combination and can be used in future studies. We also observed moderate clinical activity in patients with advanced solid tumors that had received numerous prior therapies.

Combination antiangiogenic tyrosine kinase inhibition and anti-PD1 immunotherapy in metastatic renal cell carcinoma: A retrospective analysis of safety, tolerance, and clinical outcomes

INTRODUCTION

Two separate antiangiogenic tyrosine kinase inhibitors (TKIs) and immunotherapy (IO) combinations are FDA-approved as front-line treatment for metastatic renal cell carcinoma (mRCC). Little is known about off-protocol and post-front-line experience with combination TKI-IO approaches.

METHODS

We conducted a retrospective analysis of mRCC patients who received combination TKI-IO post-first-line therapy between November 2015 and January 2019 at MD Anderson Cancer Center and Duke Cancer Institute. Chart review detailed patient characteristics, treatments, toxicity, and survival. Independent radiologists, blinded to clinical data, assessed best radiographic response using RECIST v1.1.

RESULTS

We identified 48 mRCC patients for inclusion: median age 65 years, 75.0% clear cell histology, 68.8% IMDC intermediate risk, and median two prior systemic therapies. TKI-IO combinations included nivolumab-cabozantinib (N +C; 24 patients), nivolumab-pazopanib (N+P; 13), nivolumab-axitinib (6), nivolumab-lenvatinib (2), and nivolumab-ipilimumab-cabozantinib (3). The median progression-free survival was 11.6 months and the median overall survival was not reached. Response data were available in 45 patients: complete response (CR; n = 3, 6.7%), partial response (PR; 20, 44.4%), stable disease (SD; 19, 42.2%), and progressive disease (3, 6.7%). Overall response rate was 51% and disease control rate (CR+PR+SD) was 93%. Only one patient had a grade ≥3 adverse event.

CONCLUSION

To our knowledge, this is the first case series reporting off-label use of combination TKI-IO for mRCC. TKI-IO combinations, particularly N+P and N+C, are well tolerated and efficacious. Although further prospective research is essential, slow disease progression on IO or TKI monotherapy may be safely controlled with addition of either TKI or IO.

Summary From the First Kidney Cancer Research Summit, September 12-13, 2019: A Focus on Translational Research

Kidney cancer is one of the 10 most common cancers both in the United States and worldwide. Until this year, there had not previously been a conference focused on translational studies in the broad and heterogeneous group of kidney cancers. Therefore, a group of researchers, clinicians, and patient advocates dedicated to renal cell carcinoma launched the Kidney Cancer Research Summit (KCRS) to spur collaboration and further therapeutic advances in these tumors. This commentary aims to summarize the oral presentations and serve as a record for future iterations of this meeting. The KCRS sessions addressed the tumor microenvironment, novel methods of drug delivery, single cell sequencing strategies, novel immune checkpoint blockade and cellular therapies, predictive biomarkers, and rare variants of kidney cancers. In addition, the meeting included 2 sessions to promote scientific mentoring and kidney cancer research collaborations. A subsequent KCRS will be planned for the fall of 2020.

Nephrotoxicity of immune checkpoint inhibitors beyond tubulointerstitial nephritis: single-center experience

RATIONALE & OBJECTIVE

The approved therapeutic indication for immune checkpoint inhibitors (CPIs) are rapidly expanding including treatment in the adjuvant setting, the immune related toxicities associated with CPI can limit the efficacy of these agents. The literature on the nephrotoxicity of CPI is limited. Here, we present cases of biopsy proven acute tubulointerstitial nephritis (ATIN) and glomerulonephritis (GN) induced by CPIs and discuss potential mechanisms of these adverse effects.

STUDY DESIGN, SETTING, & PARTICIPANTS

We retrospectively reviewed all cancer patients from 2008 to 2018 who were treated with a CPI and subsequently underwent a kidney biopsy at The University of Texas MD Anderson Cancer Center.

RESULTS

We identified 16 cases diagnosed with advanced solid or hematologic malignancy; 12 patients were male, and the median age was 64 (range 38 to 77 years). The median time to developing acute kidney injury (AKI) from starting CPIs was 14 weeks (range 6-56 weeks). The average time from AKI diagnosis to obtaining renal biopsy was 16 days (range from 1 to 46 days). Fifteen cases occurred post anti-PD-1based therapy. ATIN was the most common pathologic finding on biopsy (14 of 16) and presented in almost all cases as either the major microscopic finding or as a mild form of interstitial inflammation in association with other glomerular pathologies (pauci-immune glomerulonephritis, membranous glomerulonephritis, C3 glomerulonephritis, immunoglobulin A (IgA) nephropathy, or amyloid A (AA) amyloidosis). CPIs were discontinued in 15 out of 16 cases. Steroids and further immunosuppression were used in most cases as indicated for treatment of ATIN and glomerulonephritis (14 of 16), with the majority achieving complete to partial renal recovery.

CONCLUSIONS

Our data demonstrate that CPI related AKI occurs relatively late after CPI therapy. Our biopsy data demonstrate that ATIN is the most common pathological finding; however it can frequently co-occur with other glomerular pathologies, which may require immune suppressive therapy beyond corticosteroids. In the lack of predictive blood or urine biomarker, we recommend obtaining kidney biopsy for CPI related AKI.

Abstract B40: Perturbation of proteostasis is lethal in SMARCB1-deficient tumors

Alterations in the SWI/SNF chromatin remodeling complex have been implicated in human malignancies. Biallelic inactivation of the core subunits SMARCB1 and SMARCA4 are associated with particularly aggressive forms of pediatric cancer known as malignant rhabdoid tumors (MRTs) and atypical theratoid/rhabdoid tumors (AT/RTs). MRTs and AT/RTs are characterized by simple genomes and lack of somatic events, suggesting that dysregulation of SWI/SNF machinery is sufficient to induce a highly malignant state. However, the lack of a conditional genetic model of MRT has precluded the investigation of the molecular bases and dependencies associated with SMARCB1 loss. To this aim, we have developed a novel embryonic mosaic mouse model of MRTs of the liver. Using this mouse model, we performed a systematic functional investigation of vulnerabilities in the context of SMARCB1 loss in order to identify novel treatments for these diseases. Embryonic mosaic models of MRTs of the liver were generated by transuterine delivery of adenoviral vectors carrying the Cre recombinase under a tissue-specific promoter (Adx-Alb-Cre) to target SMARCB1LoxP/LoxP embryos at embryonic day E12-14 in order to study the effect of SMARCB1 ablation on development and tumorigenesis. Such an approach allowed us to target the developing liver epithelial compartment and to bypass the perinatal lethality observed with tissue-specific Cre deleter strains. This approach results in postnatal expansion of the epithelial compartment and in the emergence of rhabdoid tumors in a subset of cases. Upon investigation of the early effects of SMARCB1 ablation during mouse development and tumorigenesis, we found that livers in these embryonic mosaic murine models undergo profound metabolic changes resulting in a dramatic activation of cellular programs involved in the maintenance of proteostasis in response to ER stress and autophagy. To functionally validate the hypothesis that SMARCB1 loss confers sensitivity to proteotoxic agents, embryonic mosaic murine models of MRTs of the liver were treated with combinations of bortezomib and chloroquine, resulting in suppression of tumor growth and prolonged survival. Murine transplantation models of MRT treated with combinations of bortezomib and chloroquine also resulted in a significant increase in survival. Additionally, immunohistochemical studies of pediatric MRTs showed significant accumulation of markers of ER stress, and autophagy in comparison to normal tissue. The use of a novel embryonic mosaic models of MRT demonstrated that SMARCB1 disruption during liver embryogenesis caused activation of anabolic pathways and an increase in UPR, ER stress response, and autophagy. Overall, our preclinical study provides the rationale for a novel therapeutic approach aimed at exploiting a “collateral proteopathy” characteristic of SMARCB1-deficient malignancies and at the repositioning of existing drugs that have already shown acceptable toxicity profiles.

Citation Format: Melinda Soeung, Alessandro Carugo, Frederick Scott Robinson, Rosalba Minelli, Federica Carbone, Anirban Maitra, Andrea Viale, Charles W.M. Roberts, Nizar Tannir, Giulio F. Draetta, Giannicola Genovese. Perturbation of proteostasis is lethal in SMARCB1-deficient tumors [abstract]. In: Proceedings of the AACR Special Conference: Pediatric Cancer Research: From Basic Science to the Clinic; 2017 Dec 3-6; Atlanta, Georgia. Philadelphia (PA): AACR; Cancer Res 2018;78(19 Suppl):Abstract nr B40.

Abstract A03: Perturbation of proteostasis is lethal in SMARCB1-deficient tumors

Alterations in chromatin remodeling genes have been increasingly implicated in human oncogenesis. The SWI/SNF complex, specifically, is involved in a plethora of biologic functions including cell cycle regulation, terminal differentiation, and regulation of cell metabolism. The crucial chromatin-remodeling function of the SWI/SNF complex during organogenesis and tissue specification is further supported by clinical data showing that the biallelic inactivation of the core subunits SMARCB1 and SMARCA4 results in the emergence of extremely aggressive pediatric malignancies characterized by a dramatic impairment of cell cycle regulation and cellular differentiation programs, resulting in highly lethal diseases characterized by early onset, widespread metastatic dissemination, and resistance to chemotherapy. So far the lack of conditional genetic models of malignant rhabdoid tumors (MRTs) made difficult to investigate the molecular bases of malignant transformation as well as the existence of dependencies associated with SMARCB1 loss. In order to identify the functional vulnerabilities of SMARCB1-deficient cancers, we developed an embryonic mosaic model of malignant rhabdoid tumors (MRTs) that faithfully recapitulates the clinicopathologic features of human disease. By using this novel experimental system we discovered that, upon SMARCB1 ablation, embryonic epithelial progenitors undergo a profound anabolic reprogramming resulting in a global increase in protein biosynthesis and in the adaptive activation of UPR and ER stress response. As a consequence, murine and human SMARCB1-deficient malignancies display an exquisite sensitivity to agents inducing proteotoxic stress and to the pharmacologic and genetic perturbation of autophagy. Our findings, therefore, have immediate clinical implications, paving the way for drug repositioning trials investigating combinations of agents with already known safety profiles targeting simultaneously UPR and the authopagic catabolic machinery in a class of orphan diseases affecting children with limited therapeutic options.

Note: This abstract was not presented at the conference.

Citation Format: Giannicola Genovese, Alessandro Carugo, Rosalba Minelli, Frederick, Scott Robinson, Pavlos Msaouel, Tim Heffernan, Andrea Viale, Nizar Tannir, Giulio Draetta. Perturbation of proteostasis is lethal in SMARCB1-deficient tumors [abstract]. In: Proceedings of the AACR Special Conference: Advances in Modeling Cancer in Mice: Technology, Biology, and Beyond; 2017 Sep 24-27; Orlando, Florida. Philadelphia (PA): AACR; Cancer Res 2018;78(10 Suppl):Abstract nr A03.

First-line vascular endothelial growth factor targeted therapy in renal cell carcinoma: priming the tumor microenvironment for immunotherapy

Despite improved outcomes with systemic vascular endothelial growth factor (VEGF)-targeted agents in patients with advanced renal cell carcinoma (RCC), the majority of patients will eventually develop treatment resistance and disease progression. With the emergence of checkpoint inhibitors as potential treatment approaches, studies suggest that ideally combining or sequencing them with VEGF receptor (VEGFR)-tyrosine kinase inhibitors (TKIs) may provide more effective treatments that reduce or delay disease progression. Indeed, preliminary evidence suggests that VEGFR-TKIs can reverse immunosuppressive effects in the tumor microenvironment, potentially enhancing the effects of subsequent immunotherapy with checkpoint inhibitors. However, questions remain regarding the most effective treatment sequences or combinations with VEGFR-TKIs and checkpoint inhibitors. This review discusses the potential role of first-line VEGFR-TKIs in priming the tumor microenvironment for immunotherapy.

Sarcomatoid Renal Cell Carcinoma Has a Distinct Molecular Pathogenesis, Driver Mutation Profile, and Transcriptional Landscape

Purpose: Sarcomatoid renal cell carcinoma (SRCC) ranks among the most aggressive clinicopathologic phenotypes of RCC. However, the paucity of high-quality, genome-wide molecular examinations of SRCC has hindered our understanding of this entity.Experimental Design: We interrogated the mutational, copy number, and transcriptional characteristics of SRCC and compared these data with those of nonsarcomatoid RCC (RCC). We evaluated whole-exome sequencing, single-nucleotide polymorphism, and RNA sequencing data from patients with SRCC (n = 65) and RCC (n = 598) across different parent RCC subtypes, including clear-cell RCC, papillary RCC, and chromophobe RCC subtypes.Results: SRCC was molecularly discrete from RCC and clustered according to its parent RCC subtype, though with upregulation of TGFβ signaling across all subtypes. The epithelioid (E-) and spindled (S-) histologic components of SRCC did not show differences in mutational load among cancer-related genes despite a higher mutational burden in S-. Notably, sarcomatoid clear-cell RCC (SccRCC) showed significantly fewer deletions at 3p21-25, a lower rate of two-hit loss for VHL and PBRM1, and more mutations in PTEN, TP53, and RELN compared with ccRCC. A two-hit loss involving VHL predicted for ccRCC and a better prognosis, whereas mutations in PTEN, TP53, or RELN predicted for SccRCC and worse prognosis.Conclusions: SRCC segregates by parent subtype, and SccRCC has a fundamentally different early molecular pathogenesis, usually lacking the classic 3p21-25 deletion and showing distinctive mutational and transcriptional profiles. These features prompt a more precise molecular classification of RCC, with diagnostic, prognostic, and therapeutic implications. Clin Cancer Res; 23(21); 6686-96. ©2017 AACRSee related commentary by Bergerot et al., p. 6381.

Abstract 3291: Development of a novel prognostic scoring system for patient selection in immune checkpoint inhibitor phase 1 clinical trials

Purpose: To develop a prognostic scoring system for selecting patients for immune checkpoint inhibitor (ICI) phase 1 clinical trials.

Background: The Royal Marsden Hospital (RMH) and MD Anderson (MDA) prognostic scoring systems have been validated for patients in phase 1 clinical trials treated with cytotoxic chemotherapy and targeted therapy, but no such scoring system has been validated to help select patients entering ICI clinical trials.

Methods: We analyzed clinical data from patients treated in phase 1 ICI clinical trials (with anti-CTLA4 and anti-PD1 antibody therapy) at the MD Anderson Center for Targeted Therapy. Sixteen clinical factors were studied. Recursive partitioning analysis identified cut-points for each clinical factor and a Cox proportional hazards regression model was used to identify factors independently affecting overall survival.

Results: Among 172 patients treated with ICI therapy (105 CTLA4-based and 67 PD1-based) between January 2013 and November 2015, the median age was 60 years (range: 19-86 years) and 87 (51%) were male. The most common tumor types treated included renal cell carcinoma (n = 25; 15%), non-small cell lung cancer (n = 21; 12%), melanoma (n = 17; 10%), sarcoma (n = 14; 8%), gastrointestinal stromal tumors (n = 10; 6%), prostate cancer (n = 6; 3%), and colorectal cancer (n = 6; 3%). Seven factors were independently associated with significantly worse overall survival: age &gt;52 years (hazard ratio [HR] 1.59, 95% confidence interval [CI] 1.1-2.4), Eastern Cooperative Oncology Group performance status &gt;1 (HR 2.81, 95% CI 1.3-6.3), lactate dehydrogenase &gt;466 U/L (HR 2.1, 95% CI 1.4-3.2), platelet count &gt;300 × 109/L (HR 1.8, 95% CI 1.2-2.8), absolute neutrophil count &gt;4.9 × 109/L (HR 2.3, 95% CI 1.5-3.5), absolute lymphocyte count &lt;1.8 × 109/L (HR 3.3, 95% CI 1.9-5.7), and liver metastases (HR 1.8, 95% CI 1.2-2.6). An index was created whereby the cohort was divided into four risk groups based on the number of factors present: 0-2, 3, 4, or 5-6. Median overall survival was 24.2 months (0-2), 11.6 months (3), 8.0 months (4), and 3.8 months (5-6); log rank test, p &lt; 0.0001. The Harrell c-index of this scoring system was 0.72, indicating significant predictability.

Conclusion: We have developed a novel “MDA ICI” prognostic scoring system incorporating seven clinical parameters with prognostic significance for patients in phase 1 clinical trials treated with immune checkpoint inhibitors. Unlike in the RMH and MDA prognostic scoring systems, albumin level and number of metastatic sites did not independently correlate with overall survival. Prospective evaluation and external validation of our novel prognostic scoring system is warranted and may help better select patients for future clinical trials of checkpoint inhibitors.

Citation Format: Shiraj Sen, Kenneth Hess, David Hong, Aung Naing, Sarina Piha-Paul, Filip Janku, Siqing Fu, Holly Liu, Yunfang Jiang, Rahil Khanji, Daniel Karp, Apostolia Tsimberidou, Nizar Tannir, Funda Meric-Bernstam, Vivek Subbiah. Development of a novel prognostic scoring system for patient selection in immune checkpoint inhibitor phase 1 clinical trials [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3291. doi:10.1158/1538-7445.AM2017-3291

Abstract CT083: Clinical activity, immune and molecular correlates of nivolumab vs. nivolumab plus bevacizumab vs nivolumab plus ipilimumab in metastatic renal cell carcinoma

Background: Immune checkpoint blockade including anti-CTLA-4 (ipilimumab, BMS) and anti-PD1 (nivolumab, BMS) as monotherapies have been known to have clinical activity against metastatic renal cell carcinoma (MRCC), but with relatively low clinical response rate (10-25%). Anti-VEGF antibody bevacizumab is a standard therapy for MRCC also with a low response rate (&lt;20%). Since anti-PD1 and anti-CTLA-4 use distinct mechanisms for T cell activation and bevacizumab can promote the function of antigen presenting cells, we hypothesize that combination therapy with nivolumab + bevacizumab or nivolumab + ipilimumab will lead to measurable immunological changes and improved clinical activity.

Methods: In this open-label, pilot, pre-surgical/pre-biopsy trial (NCT02210117), adults with MRCC without prior immune checkpoint therapy and anti-VGEF therapy were enrolled, stratified by planned surgical procedure, and randomized 1:2:1 to receive nivolumab monotherapy, nivolumab + bevacizumab or nivolumab + ipilimumab, followed by cytoreductive nephrectomy, metastasectomy, or post-treatment biopsy, and subsequent maintenance therapy with nivolumab for up to 2 years until disease progression and intolerable toxicity. Pre- and post-treatment blood and tumor samples were obtained for dynamic monitoring of immune and molecular correlates to clinical activity.

Results: Sixty patients were treated (median duration 17.1 weeks, range 2.74 to 85.1 weeks as of 12/6/16). Fourty-four were evaluable for clinical responses post-procedures. Five of 12 (42%) nivolumab monotherapy treated patients had partial response (PR), 4 (33%) had stable disease (SD), and 3 (25%) had progression of disease (PD) and 0 withdrew early (W). In the nivolumab + bevacizumab arm, 1 of 19 (5%) had complete response and 9 (47%) patients had PR, for a response rate of 53%, 3 (16%) had SD, 3 (16%) with PD and 3 (16%) W. In the nivolumab + ipilimumab arm, 5 of 13 (38%) patients had PR, 1 (8%) had SD and 5 (38%) had PD and 2 (15%) W. Treatment was generally well tolerated with mostly grade 1 or 2 adverse events. Grade 3 or higher toxicities were 19% in the nivolumab arm, 41% in the nivolumab + bevacizumab arm (including 17% bevacizumab-specific hypertension that was well controlled by anti-hypertensive medications), and 27% in the nivolumab + ipilimumab arm. Correlative laboratory studies including flow cytometry, IHC, and gene profiling analysis identified a number of immune gene signatures including an IFN-γ gene signature that we will report in more details.

Conclusions: Combination therapy with nivolumab + bevacizumab and nivolumab + ipilimumab showed promising clinical activities in patients with MRCC. Immune and molecular correlative studies may allow us to identify novel biomarkers that can be used for correlation with clinical outcomes in patients with MRCC.

Citation Format: Jianjun Gao, Jose A. Karam, Christopher G. Wood, Surena Matin, Kamran Ahrar, Eric Jonasch, Nizar Tannir, Matthew Campell, Chaan S. Ng, Rebecca S. Slack, Priya Rao, James P. Allison, Jorge M. Blando, Luis M. Vence, Sreyashi Basu, Hao Zhao, Tenghui Chen, Hong Chen, Padmanee Sharma. Clinical activity, immune and molecular correlates of nivolumab vs. nivolumab plus bevacizumab vs nivolumab plus ipilimumab in metastatic renal cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT083. doi:10.1158/1538-7445.AM2017-CT083

Abstract A194: PEGylated human IL-10 (AM0010) in advanced solid tumors

Purpose

PEGylated IL-10 induces the rejection of tumors in mice and establishes immunological memory. PEG-IL-10 induces phosphorylation and activation of the anti-apoptotic STAT3 in tumor infiltrating activated CD8 T cells. This leads to the expansion of tumor reactive CD8 T cells both within the tumor and in the periphery. The primary objective of this phase 1 study is to establish the safety, tolerability and the anti-tumor-activity of human PEGylated IL-10 (AM0010). Other objectives include pharmacokinetics, AM0010 immunogenicity and AM0010 induced immune activation.

Procedures

Patients with advanced melanoma, renal cell cancer, colorectal cancer, prostate cancer, ovarian cancer and pancreatic cancer were enrolled in escalating cohorts of 3-6 patients each followed by expansion cohorts. AM0010 was self-administrated daily subcutaneously at doses of 1 to 40 μg/kg. PK, anti-drug antibodies and immune responses were monitored.

Results

More than 90 patients were enrolled in escalation and expansion cohorts with AM0010 monotherapy at doses between 1 and 40 μg/kg. An MTD is not yet established through the planned maximally administered dose. Common treatment related adverse events (TrAE) included injection site reaction, rash, fatigue, thrombocytopenia and anemia. Most adverse events were low grade. G3 adverse events were observed including anemia, thrombocytopenia, rash, increased lipase, dyslipidemia, transaminitis. Only one patient discontinued treatment due to TrAEs. On continuous dosing the terminal half-life of AM0010 half-life is estimated to be 24 hrs. Exposures increased linearly with increasing doses. At the therapeutic dose (&gt; 20 μg/kg), AM00010 induced a characteristic immune activation signature, detectable in the serum of patients: The Th1 cytokine IL-18 was dose dependently increased in all patients; IFNg, IL-4, GM-CSF, IL-7 and FasL were elevated in every patient dosed at the therapeutic dose. AM0010 also induced a reduction of TGFβ in the serum. AM0010 treatment induced an increase of activated PD-1 positive CD8 T cells both in the tumor tissue and in circulation. The immune activation observed in patients was consistent with the CD8 mediated tumor immunity observed in preclinical models.

As monotherapy, partial responses (PR) were observed in patients with RCC, melanoma and lymphoma. In particular, 19% of RCC patients, had a PR and an additional 62% had stable disease (n = 16). In addition, prolonged stable disease with or without tumor reductions were observed in several other indications, including patients with pancreatic, lung, ovarian or colon cancer.

Conclusion

In Monotherapy, AM0010 has a well-tolerated safety profile and leads to sustained and systemic immune stimulation. The pharmacodynamics and clinical activity observed support the ongoing monotherapy expansions and combination regimens with checkpoint inhibitors as well as cytotoxic chemotherapies.

Trial registration: www.clinicaltrials.gov NCT02009449

Citation Format: Jeffrey R. Infante, Aung Naing, Kyriakos P. Papadopoulos, Karen A. Autio, Patrick A. Ott, Deborah J. Wong, Gerald S. Falchook, Manish Patel, Shubham Pant, Melinda Whiteside, Johanna C. Bendell, Todd M. Bauer, Filip Janku, Milind Javle, Rivka Colen, Nizar Tannir, Martin Oft. PEGylated human IL-10 (AM0010) in advanced solid tumors. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr A194.

Posttraumatic stress and depressive symptoms in renal cell carcinoma: association with quality of life and utility of single-item distress screening

OBJECTIVE

The purpose of this study was to examine the prevalence of posttraumatic stress symptoms (PTSS) in patients with renal cell carcinoma (RCC), the associations and co-occurrence between PTSS, depressive, and other cancer-related symptoms and the ability of a single-item distress question to identify patients with PTSS.

METHODS

Patients with stage I-IV RCC completed assessments of depressive symptoms (Center for Epidemiologic Studies Depression Scale), PTSS (Impact of Event Scale), cancer-related symptoms (MD Anderson Symptom Inventory), fatigue (Brief Fatigue Inventory), and sleep disturbance (Pittsburgh Sleep Quality Index). We used the distress item on the MD Anderson Symptom Inventory as a distress screener and general linear model analyses to test study hypotheses.

RESULTS

Of the 287 patients (29% stage IV; 42% female; mean age = 58 years), 46% (n = 131) reported psychiatric symptoms with 15% (n = 44) reporting comorbid clinical levels of depressive symptoms and PTSS, 24% (n = 70) PTSS alone, and 6% (n = 17) depressive symptoms alone. Controlling for age, gender, and stage, patients with comorbid depressive symptoms and PTSS reported more cancer-related symptoms (p < 0.0001), fatigue (p < 0.0001), and sleep disturbance (p = 0.0003) than those with PTSS alone and more cancer-related symptoms (p = 0.002) and fatigue (p = 0.09) than those with depressive symptoms alone. Sensitivity analyses revealed that 26.9% of negative cases on the distress item fell within the clinical range of the Impact of Event Scale and 9.3% of negative cases met caseness on the Center for Epidemiologic Studies Depression Scale.

CONCLUSIONS

Posttraumatic stress symptoms occurred both independently and comorbid with depressive symptoms in patients with RCC. PTSS were correlated with overall cancer symptom burden. Single-item distress screening was less sensitive in detecting PTSS than depressive symptoms. Therefore, additional screening strategies are required in the clinical setting.

Bevacizumab/high-dose chemotherapy with autologous stem-cell transplant for poor-risk relapsed or refractory germ-cell tumors

BACKGROUND

High-dose chemotherapy (HDC) using sequential cycles of carboplatin/etoposide is curative for relapsed germ-cell tumors (GCT). However, outcomes of high-risk patients in advanced relapse remain poor. We previously developed a new HDC regimen combining infusional gemcitabine with docetaxel/melphalan/carboplatin (GemDMC), with preliminary high activity in refractory GCT. Given the high vascular endothelial growth factor expression in metastatic GCT and the synergy between bevacizumab and chemotherapy, we studied concurrent bevacizumab and sequential HDC using GemDMC and ifosfamide/carboplatin/etoposide (ICE) in patients with poor-risk relapsed or refractory disease.

PATIENTS AND METHODS

Eligibility criteria included intermediate/high-risk relapse (Beyer Model), serum creatinine ≤ 1.8 mg/dl and adequate pulmonary/cardiac/hepatic function. Patients received sequential HDC cycles with bevacizumab preceding GemDMC (cycle 1) and ICE (cycle 2). The trial was powered to distinguish a target 50% 2-year relapse-free survival (RFS) from an expected 25% 2-year RFS in this population.

RESULTS

We enrolled 43 male patients, median age 30 (20-49) years, with absolute refractory (N = 20), refractory (N = 17) or cisplatin-sensitive (N = 6) disease, after a median 3 (1-5) prior relapses. Disease status right before HDC was unresponsive (N = 24, progressive disease 22, stable disease 2), partial response with positive markers (PRm(+)) (N = 8), PRm(-) (N = 7) or complete response (N = 4). Main toxicities were mucositis and renal. Four patients (three with baseline marginal renal function) died from HDC-related complications. Tumor markers normalized in 85% patients. Resection of residual lesions (N = 13) showed necrosis (N = 4), mature teratoma (N = 2), necrosis/teratoma (N = 3) and viable tumor (N = 4). At median follow-up of 46 (9-84) months, the RFS and overall survival rates are 55.8% and 58.1%, respectively.

CONCLUSIONS

Sequential bevacizumab/GemDMC-bevacizumab/ICE shows encouraging outcomes in heavily pretreated and refractory GCT, exceeding the results expected in this difficult to treat population.

CLINICALTRIALSGOV

NCT00936936.

Biphasic components of sarcomatoid clear cell renal cell carcinomas are molecularly similar to each other, but distinct from, non-sarcomatoid renal carcinomas

Sarcomatoid transformation, wherein an epithelioid carcinomatous tumour component coexists with a sarcomatoid histology, is a predictor of poor prognosis in clear cell renal cell carcinoma. Our understanding of sarcomatoid change has been hindered by the lack of molecular examination. Thus, we sought to characterize molecularly the biphasic epithelioid and sarcomatoid components of sarcomatoid clear cell renal cell carcinoma and compare them to non-sarcomatoid clear cell renal cell carcinoma. We examined the transcriptome of the epithelioid and sarcomatoid components of advanced stage sarcomatoid clear cell renal cell carcinoma (n=43) and non-sarcomatoid clear cell renal cell carcinoma (n=37) from independent discovery and validation cohorts using the cDNA microarray and RNA-seq platforms. We analyzed DNA copy number profiles, generated using SNP arrays, from patients with sarcomatoid clear cell renal cell carcinoma (n=10) and advanced non-sarcomatoid clear cell renal cell carcinoma (n=155). The epithelioid and sarcomatoid components of sarcomatoid clear cell renal cell carcinoma had similar gene expression and DNA copy number signatures that were, however, distinct from those of high-grade, high-stage non-sarcomatoid clear cell renal cell carcinoma. Prognostic clear cell renal cell carcinoma gene expression profiles were shared by the biphasic components of sarcomatoid clear cell renal cell carcinoma and the sarcomatoid component showed a partial epithelial-to-mesenchymal transition signature. Our genome-scale microarray-based transcript data were validated in an independent set of sarcomatoid and non-sarcomatoid clear cell renal cell carcinomas using RNA-seq. Sarcomatoid clear cell renal cell carcinoma is molecularly distinct from non-sarcomatoid clear cell renal cell carcinoma, with its genetic programming largely shared by its biphasic morphological components. These data explain why a low percentage of sarcomatoid histology augurs a poor prognosis; suggest the need to modify the pathological grading system and introduce the potential for candidate biomarkers to detect sarcomatoid change preoperatively without specifically sampling the histological sarcomatoid component.

Resistance to Antiangiogenic Therapy Is Associated with an Immunosuppressive Tumor Microenvironment in Metastatic Renal Cell Carcinoma

Renal cell carcinoma (RCC) is an immunogenic and proangiogenic cancer, and antiangiogenic therapy is the current mainstay of treatment. Patients with RCC develop innate or adaptive resistance to antiangiogenic therapy. There is a need to identify biomarkers that predict therapeutic resistance and guide combination therapy. We assessed the interaction between antiangiogenic therapy and the tumor immune microenvironment and determined their impact on clinical outcome. We found that antiangiogenic therapy-treated RCC primary tumors showed increased infiltration of CD4(+) and CD8(+) T lymphocytes, which was inversely related to patient overall survival and progression-free survival. Furthermore, specimens from patients treated with antiangiogenic therapy showed higher infiltration of CD4(+)FOXP3(+) regulatory T cells and enhanced expression of checkpoint ligand programed death-ligand 1 (PD-L1). Both immunosuppressive features were correlated with T-lymphocyte infiltration and were negatively related to patient survival. Treatment of RCC cell lines and RCC xenografts in immunodeficient mice with sunitinib also increased tumor PD-L1 expression. Results from this study indicate that antiangiogenic treatment may both positively and negatively regulate the tumor immune microenvironment. These findings generate hypotheses on resistance mechanisms to antiangiogenic therapy and will guide the development of combination therapy with PD-1/PD-L1-blocking agents.

Creation of a Prognostic Index for Spine Metastasis to Stratify Survival in Patients Treated With Spinal Stereotactic Radiosurgery: Secondary Analysis of Mature Prospective Trials

PURPOSE

There exists uncertainty in the prognosis of patients following spinal metastasis treatment. We sought to create a scoring system that stratifies patients based on overall survival.

METHODS AND MATERIALS

Patients enrolled in 2 prospective trials investigating stereotactic spine radiation surgery (SSRS) for spinal metastasis with ≥ 3-year follow-up were analyzed. A multivariate Cox regression model was used to create a survival model. Pretreatment variables included were race, sex, age, performance status, tumor histology, extent of vertebrae involvement, previous therapy at the SSRS site, disease burden, and timing of diagnosis and metastasis. Four survival groups were generated based on the model-derived survival score.

RESULTS

Median follow-up in the 206 patients included in this analysis was 70 months (range: 37-133 months). Seven variables were selected: female sex (hazard ratio [HR] = 0.7, P=.02), Karnofsky performance score (HR = 0.8 per 10-point increase above 60, P = .007), previous surgery at the SSRS site (HR = 0.7, P=.02), previous radiation at the SSRS site (HR = 1.8, P=.001), the SSRS site as the only site of metastatic disease (HR = 0.5, P=.01), number of organ systems involved outside of bone (HR = 1.4 per involved system, P<.001), and >5 year interval from initial diagnosis to detection of spine metastasis (HR = 0.5, P < .001). The median survival among all patients was 25.5 months and was significantly different among survival groups (in group 1 [excellent prognosis], median survival was not reached; group 2 reached 32.4 months; group 3 reached 22.2 months; and group 4 [poor prognosis] reached 9.1 months; P < .001). Pretreatment symptom burden was significantly higher in the patient group with poor survival than in the group with excellent survival (all metrics, P < .05).

CONCLUSIONS

We developed the prognostic index for spinal metastases (PRISM) model, a new model that identified patient subgroups with poor and excellent prognoses.

Clinical next generation sequencing of pediatric-type malignancies in adult patients identifies novel somatic aberrations

Pediatric malignancies in adults, in contrast to the same diseases in children are clinically more aggressive, resistant to chemotherapeutics, and carry a higher risk of relapse. Molecular profiling of tumor sample using next generation sequencing (NGS) has recently become clinically available. We report the results of targeted exome sequencing of six adult patients with pediatric-type malignancies : Wilms tumor(n=2), medulloblastoma(n=2), Ewing's sarcoma( n=1) and desmoplastic small round cell tumor (n=1) with a median age of 28.8 years. Detection of druggable somatic aberrations in tumors is feasible. However, identification of actionable target therapies in these rare adult patients with pediatric-type malignancies is challenging. Continuous efforts to establish a rare disease registry are warranted.

Psychological states, serum markers and survival: associations and predictors of survival in patients with renal cell carcinoma

This study sought to determine if there was an association between prognostic-based serum biomarkers, survival, and psychosocial factors in patients with metastatic renal cell carcinoma. Associations were found between psychosocial factors and biomarker levels (hemoglobin with depressive symptoms (r = -0.29), positive affect (r = 0.30), social support (r = 0.19), and perceived stress (r = -0.27); albumin with depressive symptoms (r = -0.19), positive affect (r = 0.22), and social support (r = 0.20); alkaline phosphatase with depressive symptoms (r = 0.21), all p values <0.05. After adjustment for disease-related risk factors, only the associations between positive affect and perceived stress with hemoglobin remained significant (p's < 0.05). Positive affect (HR = 0.90; 95% CI = 0.83, 0.97; p = 0.009) and depressive symptom total scores (HR = 1.03; 95% CI = 1.01, 1.06; p = 0.013), and alkaline phosphatase (HR 2.72; 95% CI = 1.41, 5.24; p = 0.003) were associated with survival. This study suggests that measures of positive and negative psychological outlook may contribute differently to health, well-being, and survival.