Treatment and dose modifications in patients according to their DCB status.

2563 Background: Acquired resistance to systemic therapies, including immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs), is a major clinical challenge in advanced non–small cell lung cancer (NSCLC). While mechanisms of resistance to targeted therapies are well-documented, the genomic alterations associated with resistance to immunotherapy remain poorly understood. Circulating tumor DNA (ctDNA) profiling offers a non-invasive approach to identify real-time genomic changes driving resistance, providing novel insights into the underlying biology of immunotherapy failure. Methods: We performed a prospective ctDNA sequencing study in 57 advanced NSCLC patients from two cohorts: STING (n = 30, NCT04932525) and COPE (n = 27, NCT04258137). Plasma samples were collected before treatment initiation and at disease progression following objective response to anti–PD-1 therapy or TKIs. ctDNA analysis was conducted to detect emergent genomic alterations, evaluate tumor mutation burden (TMB), and quantify circulating tumor fraction (TF). Results: The study included 57 patients, with a median age of 62 years [IQR: 54.5–70], and 54.4% (31/57) were male. At disease progression, 64.9% (37/57) of patients exhibited emergent ctDNA alterations associated with secondary resistance, independent of therapy type. Among these, 70% (26/37) harbored multiple newly arising mutations. In the non–oncogene-addicted NSCLC cohort receiving anti–PD-1 therapy (n = 30), 56.6% (17/30) exhibited emergent resistance alterations, with 76.5% (13/17) harboring multiple mutations. Frequently observed aberrations included mutations in NOTCH1/3 (n = 3), KEAP1 (n = 3), KMT2B (n = 2), POLE (n = 2), SETD2 (n = 2), TYRO3 (n = 2), STK11 (n = 2), TSC2 (n = 1), TGFBR2 (n = 1), PTPN11 (n = 1), SPEN (n = 1), STAG (n = 1), CDH1 (n = 1), and CTNNB1 (n = 1). The median progression-free survival (mPFS) was 7.0 months [95% CI: 5.0–10.3]. In the anti-EGFR TKI cohort (n = 13), 84.6% (11/13) displayed emergent ctDNA alterations, including mutations in EGFR (n = 2), PIK3CA (n = 2), and MET (n = 1). The mPFS was 8.6 months [95% CI: 6.7–11.2]. TMB and circulating TF did not significantly change between baseline and progression in both cohorts. Conclusions: This study highlights the high prevalence of emergent genomic alterations detected by ctDNA in advanced NSCLC patients developing resistance to ICIs and TKIs. In the ICI-treated cohort, mutations in NOTCH1/3, KEAP1, and STK11 emerged as significant resistance drivers, consistent with their roles in immune evasion, oxidative stress regulation, and impaired immune cell infiltration, as supported by prior studies. Notably, this is the first study investigating features of ctDNA at acquired resistance to immunotherapy using an FDA-approved assay. These findings underscore the heterogeneous and polyclonal nature of resistance to ICIs.

Additional significant differences in circulating chemokines.

Cytotoxic response in tumor biopsies of patients with No DCB upon combination treatment.

Further descriptions of tumor immune infiltrates.

Adverse events emergent during treatment and related to experimental drugs by the investigators according to CTCAE Version 4.03.

Gating strategy for flow cytometry analyses of T cells infiltration on tumor biopsies.

Supplementary materials - substudy 1 statistical report

Immuno-Histo-Chemistry scoring of baseline tumor biopsies according to their DCB status.

Differential Gene Expression (DGE) of baseline tumor biopsies between patients with DCB and No DCB.

Baseline characteristics of the patients treated.

Background Tumor fraction (TF) at liquid biopsy is a potential noninvasive marker for tumor burden, but validation is needed. Purpose To evaluate TF as a potential surrogate for tumor burden, assessed at contrast-enhanced CT across diverse metastatic cancers. Methods This retrospective monocentric study included patients with cancer and metastatic disease, with TF results and contemporaneous contrast-enhanced CT performed between January 2021 and January 2023. The total tumor volume (TTV), representing CT tumor burden, was calculated by adding all lesion volumes and was computed by using manually outlined annotations of each lesion on the largest surface of the axial slice. TF greater than 10% was considered high. A training-validation split was applied. Correlations between TF and TTV were assessed using regression models and Spearman correlation coefficients. Receiver operating characteristic curve analysis established the TTV cutoff. The metastatic site, histology type, and TTV were used to predict liquid biopsy contributory status. Results Among 1065 patients (median age, 62 years [IQR: 53, 70]; 537 female), 56 288 lesions were annotated, mostly in the lung (n = 20 334), lymph nodes (n = 11 651), and liver (n = 10 277). A total of 763 liquid biopsies were contributive, 254 were noncontributive, and 48 failed. The training and validation sets included 745 and 320 patients, respectively. TF helped predict TTV with the linear model (R2 = 0.17; ρ = 0.41; P < .001). The TTV and TF categories achieved an area under the receiver operating characteristic curve (AUC) of 0.74 (95% CI: 0.71, 0.78), with an optimal cutoff of 151 cm3 for TTV and a TF cutoff of 10%. The sensitivity was 57% (204 of 359) and the specificity was 80% (525 of 658). TTV helped predict contributory status, with an AUC of 0.71 (95% CI: 0.67, 0.76) and an optimal cutoff greater than 37 cm3. Liver lesion volumes were significantly associated with a contributory liquid biopsy in the validation cohort. Conclusion While correlated, TF at liquid biopsy did not accurately represent the TTV at CT. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Koh in this issue.

Selecting patients for phase I cancer trials is crucial to ensure a sufficient life expectancy. Frail patients, better suited for palliative care, should not be exposed to new drugs with minimal benefit. Enrolling patients at high risk of early death can jeopardize the study. Our analysis of two large precision medicine studies used tumor fraction from ctDNA to develop a predictive model, demonstrating notable predictive accuracy and aiding in patient selection.

Background Platinum-sensitivity is a phenotypic biomarker of Poly (ADP-ribose) polymerase inhibitors (PARPi) sensitivity in histotypes where PARPi are approved. Approximately one-third of non-small cell lung cancers (NSCLC) are platinum-sensitive. The double-blind, randomized phase II PIPSeN (NCT02679963) study evaluated olaparib, a PARPi, as maintenance therapy for patients with platinum-sensitive advanced NSCLC. Methods Chemonaïve patients with ECOG performance status of 0–1, platinum-sensitive, EGFR - and ALK -wild-type, stage IIIB-IV NSCLC were randomized (R) to receive either olaparib (O) maintenance or a placebo (P). The primary objective was progression-free survival (PFS) from R. Secondary objectives included overall survival (OS) and safety. With an anticipated hazard ratio of 0.65, 144 patients were required to be randomized, and approximately 500 patients enrolled. Results The trial was prematurely terminated because anti-PD(L)1 therapy was approved during the trial recruitment. A total of 182 patients were enrolled, with 60 patients randomized: 33 and 27 in the O and P arms, respectively. Patient and tumor characteristics were well-balanced between arms, except for alcohol intake (33% vs 11% in the O and P arms, respectively, p = 0.043). The median PFS was 2.9 and 2.0 months in the O and P arms, respectively (logrank p = 0.99). The median OS was 9.4 and 9.5 months in the O and P arms, respectively ( p = 0.28). Grade ≥3 toxicities occurred in 15 and 8 patients in O and P arms, with no new safety concerns. Conclusion PIPSeN was terminated early after enrollment of only 50% of the pre-planned population, thus being statistically underpowered. Olaparib maintenance did neither improve median PFS nor OS in this patient population.

BACKGROUND:Understanding the resistance mechanisms of tumor is crucial for advancing cancer therapies. The prospective MATCH-R trial (NCT02517892), led by Gustave Roussy, aimed to characterize resistance mechanisms to cancer treatments through molecular analysis of fresh tumor biopsies. This report presents the genomic data analysis of the MATCH-R study conducted from 2015 to 2022 and focuses on targeted therapies. METHODS:The study included resistant metastatic patients (pts) who accepted an image-guided tumor biopsy. After evaluation of tumor content (TC) in frozen tissue biopsies, targeted NGS (10 < TC < 30%) or Whole Exome Sequencing and RNA sequencing (TC > 30%) were performed before and/or after the anticancer therapy. Patient-derived xenografts (PDX) were established by implanting tumor fragments into NOD scid gamma mice and amplified up to five passages. RESULTS:A total of 1,120 biopsies were collected from 857 pts with the most frequent tumor types being lung (38.8%), digestive (16.3%) and prostate (14.1%) cancer. Molecular targetable driver were identified in 30.9% (n = 265/857) of the patients, with EGFR (41.5%), FGFR2/3 (15.5%), ALK (11.7%), BRAF (6.8%), and KRAS (5.7%) being the most common altered genes. Furthermore, 66.0% (n = 175/265) had a biopsy at progression on targeted therapy. Among resistant cases, 41.1% (n = 72/175) had no identified molecular mechanism, 32.0% (n = 56/175) showed on-target resistance, and 25.1% (n = 44/175) exhibited a by-pass resistance mechanism. Molecular profiling of the 44 patients with by-pass resistance identified 51 variants, with KRAS (13.7%), PIK3CA (11.8%), PTEN (11.8%), NF2 (7.8%), AKT1 (5.9%), and NF1 (5.9%) being the most altered genes. Treatment was tailored for 45% of the patients with a resistance mechanism identified leading to an 11 months median extension of clinical benefit. A total of 341 biopsies were implanted in mice, successfully establishing 136 PDX models achieving a 39.9% success rate. PDX models are available for EGFR (n = 31), FGFR2/3 (n = 26), KRAS (n = 18), ALK (n = 16), BRAF (n = 6) and NTRK (n = 2) driven cancers. These models closely recapitulate the biology of the original tumors in term of molecular alterations and pharmacological status, and served as valuable models to validate overcoming treatment strategies. CONCLUSION:The MATCH-R study highlights the feasibility of on purpose image guided tumor biopsies and PDX establishment to characterize resistance mechanisms and guide personalized therapies to improve outcomes in pre-treated metastatic patients.

Importance:Deregulation of anaplastic lymphoma kinase (ALK) occurs in 3-7% of advanced NSCLC mainly because of chromosomic rearrangements at the ALK locus. Next to its oncogenic function, ALK chimeric oncoprotein is a possible antigen for human immune system. The prognostic value of natural anti-ALK immunogenicity remains poorly explored in ALK ​+ ​NSCLC. We hereby report preliminary results of a plasmatic anti-ALK a-abs titration assessment in a cohort of ALK ​+ ​NSCLC pts. Objective:To evaluate the prevalence of pre-existing circulating anti-ALK a-abs in ALK ​+ ​NSCLC pts. Key secondary objectives are the assessment of anti-ALK a-abs prognostic value and association with brain metastases (BM). Design:This monocentric case series included 60 ALK ​+ ​NSCLC pts progressing on any anti-ALK TKIs between October 2015 and February 2021 ​at Gustave Roussy Cancer Campus. Fifty-six plasma samples were analyzed through a semiquantitative immunocytochemical technique. Plasma samples were obtained from two prospective studies approved by our Institutional Review Board: the MATCH-R trial (NCT02517892) and the MSN trial (RECF1256). Participants:We included pts diagnosed with unresectable stage III or IV NSCLC, either by contemporaneous or historical biopsy. ALK-rearrangement was identified by FISH, IHC or NGS. Pts were aged more than 18-year-old and had previously signed informed consent for one of the studies. Pts had received at least one anti-ALK-TKI during the disease history. Pts were not eligible if they had been diagnosed with a second cancer. Main outcomes and measures:The prevalence of plasmatic anti-ALK a-abs titer was reported as percentage. Progression-free survival, overall survival, and time to BM were analyzed using Kaplan-Meier methods. Results:We found an anti-ALK a-abs titer in 5 (9 ​%) pts. anti-ALK a-abs did not contribute to prolongation of survival. Although not significant, there was a trend towards protection against BM in the presence of anti-ALK a-abs. Conclusions and relevance:Because ALK fusion proteins are exclusively produced intracellularly, not all ALK autoantibodies may have direct anti-tumor impact with favorable prognostic value. This is the first investigation to explore the impact of circulating anti-ALK a-abs on BM. Prospective studies with longer follow-up are warranted to further explore the impact of anti-ALK a-abs on BM.

Circulating proteomes provide a snapshot of the physiological state of a human organism responding to pathogenic challenges and drug interventions. The outcomes of patients with COVID-19 and acute respiratory distress syndrome triggered by the SARS-CoV2 virus remain uncertain. Tocilizumab is an anti-interleukin-6 treatment that exerts encouraging clinical activity by controlling the cytokine storm and improving respiratory distress in patients with COVID-19. We investigate the biological determinants of therapeutic outcomes after tocilizumab treatment. Overall, 28 patients hospitalized due to severe COVID-19 who were treated with tocilizumab intravenously were included in this study. Sera were collected before and after tocilizumab, and the patient's outcome was evaluated until day 30 post-tocilizumab infusion for favorable therapeutic response to tocilizumab and mortality. Hyperreaction monitoring measurements by liquid chromatography-mass spectrometry-based proteomic analysis with data-independent acquisition quantified 510 proteins and 7019 peptides in the serum of patients. Alterations in the serum proteome reflect COVID-19 outcomes in patients treated with tocilizumab. Our results suggested that circulating proteins associated with the most significant prognostic impact belonged to the complement system, platelet degranulation, acute-phase proteins, and the Fc-epsilon receptor signaling pathway. Among these, upregulation of the complement system by activation of the classical pathway was associated with poor response to tocilizumab, and upregulation of Fc-epsilon receptor signaling was associated with lower mortality.

The circulating metabolome provides a snapshot of the physiological state of the organism responding to pathogenic challenges. Here we report alterations in the plasma metabolome reflecting the clinical presentation of COVID-19 patients with mild (ambulatory) diseases, moderate disease (radiologically confirmed pneumonitis, hospitalization and oxygen therapy), and critical disease (in intensive care). This analysis revealed major disease- and stage-associated shifts in the metabolome, meaning that at least 77 metabolites including amino acids, lipids, polyamines and sugars, as well as their derivatives, were altered in critical COVID-19 patient’s plasma as compared to mild COVID-19 patients. Among a uniformly moderate cohort of patients who received tocilizumab, only 10 metabolites were different among individuals with a favorable evolution as compared to those who required transfer into the intensive care unit. The elevation of one single metabolite, anthranilic acid, had a poor prognostic value, correlating with the maintenance of high interleukin-10 and -18 levels. Given that products of the kynurenine pathway including anthranilic acid have immunosuppressive properties, we speculate on the therapeutic utility to inhibit the rate-limiting enzymes of this pathway including indoleamine 2,3-dioxygenase and tryptophan 2,3-dioxygenase.