Supplementary Table S4 is a table showing the representativeness of study participants.

Supplementary Protocol S1 shows the entire clinical trial protocol to supplement the Materials and Methods section.

BackgroundNeomorphic isocitrate dehydrogenase (IDH) mutations lead to the accumulation of 2-hydroxyglutarate (2-HG), an oncometabolite implicated in tumor progression via inhibitory effects on alpha-ketoglutarate. Moreover, mutant IDH-dependent accumulation of 2-HG results in homologous recombination deficiency (HRD), which preclinically renders tumors sensitive to poly(adenosine diphosphate ribose) polymerase inhibitors. Here, the results of the cholangiocarcinoma (CCA) arm of the National Cancer Institute (NCI) 10129 olaparib in IDH-mutant solid tumors basket trial are reported.MethodsOlaparib 300 mg twice daily was evaluated in an open-label, phase 2 clinical trial for treatment-refractory IDH-mutant solid tumors. Patients in the IDH-mutant CCA arm enrolled in two cohorts: (1) IDH inhibitor (IDHi) pretreated and (2) IDHi untreated, with a primary end point of overall response rate.ResultsNCI 10129 enrolled 30 patients with IDH-mutant CCA with no objective responses seen, and recruitment was closed early. Median progression-free survival (PFS) was 2.4 months (95% CI, 1.9 to 6.5 months) and median overall survival was 12.9 months (95% CI, 6.3 months to not reached). Eight patients (27%) had clinical benefit (CB), with a PFS of >= 6 months. Patients with CB had lower baseline 2-HG levels compared to those without CB (1.4 vs. 5.9 mu mol/L; p = .01).ConclusionsOlaparib does not have sufficient single-agent activity to warrant further development in IDH-mutant CCA. However, a subgroup of patients demonstrated CB, and exploratory analysis revealed this subgroup to be enriched for lower baseline 2-HG levels. Future clinical trials leveraging the HRD properties of IDH mutations are warranted with enhanced patient selection and novel combination therapies.

Abstract We sought to evaluate the efficacy of WEE1 inhibitor adavosertib in patients with solid tumor malignancies (cohort A) and clear cell renal cell carcinoma (ccRCC; cohort B). NCT03284385 was a parallel cohort, Simon two-stage, phase II study of adavosertib (300 mg QDAY by mouth on days 1–5 and 8–12 of each 21-day cycle) in patients with solid tumor malignancies harboring a pathogenic SETD2 mutation. The primary endpoint was the objective response rate. Correlative assays evaluated the loss of H3K36me3 by IHC, a downstream consequence of SETD2 loss, in archival tumor tissue. Eighteen patients were enrolled (9/cohort). The median age was 60 years (range 45–74). The median duration of treatment was 1.28 months (range 0–24+). No objective responses were observed in either cohort; accrual was halted following stage 1. Minor tumor regressions were observed in 4/18 (22%) evaluable patients. Stable disease (SD) was the best overall response in 10/18 (56%) patients, including three patients with SD > 4 months. One patient with ccRCC remains on treatment for >24 months. The most common adverse events of any grade were nausea (59%), anemia (41%), diarrhea (41%), and neutropenia (41%). Nine patients (50%) experienced a Grade ≥3 adverse event. Of eight evaluable archival tissue samples, six (75%) had a loss of H3K36me3 by IHC. Adavosertib failed to exhibit objective responses in SETD2-altered ccRCC and other solid tumor malignancies although prolonged SD was observed in a subset of patients. Combination approaches may yield greater depth of tumor response. Significance: WEE1 inhibition with adavosertib monotherapy demonstrated limited clinical activity in patients with SETD2-altered solid tumors despite compelling preclinical data indicating a synthetic lethal effect, which did not translate into robust tumor regression. Loss of the H3K36me3 trimethylation mark caused by SETD2-deficiency was confirmed in the majority of evaluable tumors. A subset of patients derived clinical benefit as manifested by minor tumor regressions and prolonged SD.

Background Our preclinical work revealed tumour hypoxia induces homologous recombination deficiency (HRD), increasing sensitivity to Poly (ADP-ribose) polymerase inhibitors. We aimed to induce tumour hypoxia with ramucirumab thereby sensitising tumours to olaparib. Patients and methods This multi-institution single-arm Phase 1/2 trial enrolled patients with metastatic gastroesophageal adenocarcinoma refractory to ≥1 systemic treatment. In dose escalation, olaparib was evaluated at escalating dose levels with ramucirumab 8 mg/kg day 1 in 14-day cycles. The primary endpoint of Phase 1 was the recommended Phase 2 dose (RP2D), and in Phase 2 the primary endpoint was the overall response rate (ORR). Results Fifty-one patients received ramucirumab and olaparib. The RP2D was olaparib 300 mg twice daily with ramucirumab 8 mg/kg. In evaluable patients at the RP2D the ORR was 6/43 (14%) (95% CI 4.7–25.6). The median progression-free survival (PFS) was 2.8 months (95% CI 2.3–4.2) and median overall survival (OS) was 7.3 months (95% CI 5.7–13.0). Non-statistically significant improvements in PFS and OS were observed for patients with tumours with mutations in HRD genes. Conclusions Olaparib and ramucirumab is well-tolerated with efficacy that exceeds historical controls with ramucirumab single agent for gastric cancer in a heavily pre-treated patient population.

Background: Poly-ADP ribose polymerase inhibitors (PARPi) work by impairing DNA damage repair and have demonstrated activity in patients with BRCAmt breast cancer. Their mechanism of action leads to high mutational burden and increased neoantigens suggesting tumors exposed to PARPi may have increased response to immunotherapy. Preclinical and phase I/II trials have shown evidence of antitumor effect of PARPi + PD-L1 inhibition. In this study, we assessed the efficacy of the PARPi olaparib as monotherapy vs. in combination with PD-L1 inhibitor atezolizumab in patients with BRCAmt advanced breast cancer. Methods: A multicenter, randomized, open-label, phase II study was conducted. Patients were enrolled at 20 sites in the US. Patients were allowed prior hormone or chemotherapy and randomized to receive olaparib 300 mg twice daily (O) +/- atezolizumab 1200 mg IV every 21 days (O+A) until disease progression or intolerable side effect. Patients with progression on O were allowed to crossover to O+A arm. The primary endpoint was comparison of progression free survival (PFS) between arms. Overall survival (OS) was also assessed. Safety and activity analyses were done in patients who received at least one dose of study treatment. Serial tumor biopsies were collected at baseline, 6 weeks, and progression to evaluate the effect of therapy on tumor infiltrating lymphocyte populations, whole exome DNA sequencing, and correlate with outcome to assess predictive value. Enrollment has completed and the study is ongoing. The trial is registered with ClinicalTrials.gov, NCT02849496. Results: 78 patients with BRCAmt advanced breast cancer were enrolled between 5/3/2018 and 3/17/2022 and available for analysis. Groups were generally well matched on baseline characteristics. PFS was 7.0 months (95% CI 5.5-11.5) in O arm and 7.67 months (95% CI 5.6-10) in O+A arm (p=0.92). Median OS was 26.5 months (95% CI 19.2- NR) in O arm and 22.4 months (95% CI 16.6-31.3) in O+A arm (p=0.3). In triple negative breast cancer (TNBC) subgroup (n=23), there was no significant difference in PFS (p=0.92) or OS (p=0.6). Treatment was generally well tolerated with expected side effects, with O+A group experiencing more adverse events of all grades. Analysis of tumor samples from serial biopsies will be presented separately. Conclusion: Olaparib or combination olaparib + atezolizumab resulted in clinically meaningful PFS in both treatment arms. Addition of atezolizumab did not significantly increase PFS. Treatment in both arms was generally well tolerated with expected side effects based on prior drug profiles. This is the first randomized trial to show that the addition of immunotherapy (atezolizumab) to PARPi (olaparib) in patients with advanced BRCAmt breast cancer does not add to therapeutic response but carries with it additional toxicities. Citation Format: Kristina A. Fanucci, Mary Jo Pilat, Derek Shyr, Yu Shyr, Scott A. Boerner, Diane Durecki, Anne Noonan, Vandana Abramson, Cesar Santa-Maria, Hyo Han, Rita Nanda, Elizabeth Claire Dees, Haeseong Park, Saundra Buys, Namrata Peswani, Helen Chew, Hadeel Assad, Gerburg Wulf, Angelique Richardson, Meghna S. Trivedi, Adam Brufsky, James Abbruzzese, Anosheh Afghahi, Elad Sharon, Kurt Schalper, Patricia LoRusso. Olaparib +/- atezolizumab in patients with BRCA-mutated (BRCAmt) locally advanced unresectable or metastatic (advanced) breast cancer: an open-label, multicenter, randomized phase II trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT145.

The clinical trial protocol for NCI 7977.

A full list of all adverse events.

Purpose:Isocitrate dehydrogenase (IDH) 1 and IDH2 mutations (IDH1/2mt) are frequent in glioma. Preclinical studies suggest IDH1/2mts confer “BRCAness” phenotype, a vulnerability that can be targeted through PARP inhibition. To test this hypothesis, we conducted a multicenter study of olaparib monotherapy in patients with IDH1/2mt gliomas.Methods:Patients with recurrent, contrast-enhancing IDH1/2mt gliomas were enrolled in a two-step phase II trial; the primary endpoint was overall response rate per Response Assessment in Neuro-Oncology (RANO) criteria. Olaparib 300 mg orally twice daily was given.Results:A total of 15 evaluable patients were enrolled. Histology was astrocytoma (N = 12) and oligodendroglioma (N = 3). Most toxicities were grade 1 or 2. Best response was stable disease (SD) in 9 (60%) patients. Median progression-free survival (PFS) was 3.63 months and median overall survival was 20.7 months. For patients with SD, median PFS was 5.53 months; 4 patients had SD for >6 months. Among patients with best response progressive disease (N = 6), 5 had grade 4 tumor and 4 had known CDKN2A alteration. PFS was 5.23 months for grades 2 or 3 tumors (N = 10) versus 1.8 months for grade 4 (N = 5; P = 0.0013).Conclusion:The study did not meet the prespecified response-based activity threshold for moving to step 2. However, prolonged SD was observed in patients with grades 2 and 3 histologies, suggesting olaparib monotherapy could be of clinical benefit in select populations. Grade 4 tumors per 2021 World Health Organization classification defined by histology or CDKN2A alteration derived no benefit from this drug, highlighting the usefulness of this classification for future patient stratification and trial design.Significance:A single-arm phase II trial of olaparib in IDH-mutant glioma demonstrated clinically significant prolonged SD for select patients with grade 2/3 disease, suggesting potential benefit of olaparib in IDH-mutant gliomas.

Supplementary Table 2 Pharmacokinetic parametersa of irinotecan and its main active metabolite SN-38 when irinotecan was administered as a 1.5-h intravenous infusion (100 mg/m2) alone on cycle 1 day 1 or in combination with veliparib on cycle 2 day 8

Supplementary Figure S3. pNBS1 staining post-combination treatment is limited to tumor cells.

Supplementary Figure S4. Assessment of pNBS1 in the exploratory multiplex immunofluorescence assay.

Supplementary Figure S1. Study schema.

Supplementary Table 1 Pharmacokinetic parametersa of veliparib and its main metabolite (A- 925088) when veliparib was given orally alone on cycle 2 day -1 or in combination with irinotecan on cycle 2 day 8

Waterfall plot for best response by RECIST version 1.1.

Purpose:Veliparib is a PARP inhibitor (PARPi) with activity in BRCA 1/2/PALB2-deficient tumors. Preclinical observations reveal topoisomerase inhibitors like irinotecan are synergistic with PARPi irrespective of homologous recombination deficiency (HRD), potentially expanding the role for PARPi.Experimental Design:NCI 7977 was a multicohort phase I clinical trial evaluating the safety and efficacy of multiple dose schedules of veliparib with irinotecan for solid tumors. In the intermittent veliparib cohort, escalating doses of veliparib were given twice daily at dose level (DL) 1 (50 mg) and DL 2 (100 mg) days 1–4 and 8–11 with irinotecan 100 mg/m2 days 3 and 10 in 21-day cycles.Results:Fifteen patients enrolled, 8 of 15 (53%) received ≥4 prior systemic treatments. At DL1, 1 of 6 patients experienced a dose-limiting toxicity (DLT) of diarrhea. At DL2, 9 patients were treated, with 3 unevaluable for DLT, and 2 of 6 evaluable patients experienced a DLT of grade 3 neutropenia. Irinotecan 100 mg/m2 and veliparib 50 mg twice daily was the MTD. No objective responses were observed, although 4 patients had progression-free survival >6 months.Conclusions:The MTD of intermittent veliparib is 50 mg twice daily days 1–4 and 8–11 with weekly irinotecan 100 mg/m2 days 3 and 10 every 21 days. Multiple patients experienced prolonged stable disease irrespective of HRD and prior irinotecan. However, due to the toxicities with higher dose intermittent veliparib and irinotecan, this schedule was determined too toxic for further development and the arm was closed prematurely.Significance:The combination of intermittent veliparib with weekly irinotecan was deemed too toxic for further development. Future PARPi combinations should focus on agents with nonoverlapping toxicities to improve tolerability. The treatment combination showed limited efficacy with prolonged stable disease observed in multiple heavily pretreated patients, but no objective responses were seen.

Treatment-related frequency of adverse events and laboratory abnormalities