Antibiotics (ABX) compromise the efficacy of programmed cell death protein 1 (PD-1) blockade in cancer patients, but the mechanisms underlying their immunosuppressive effects remain unknown. By ...inducing the down-regulation of mucosal addressin cell adhesion molecule 1 (MAdCAM-1) in the ileum, post-ABX gut recolonization by
species drove the emigration of enterotropic α4β7
CD4
regulatory T 17 cells into the tumor. These deleterious ABX effects were mimicked by oral gavage of
species, by genetic deficiency, or by antibody-mediated neutralization of MAdCAM-1 and its receptor, α4β7 integrin. By contrast, fecal microbiota transplantation or interleukin-17A neutralization prevented ABX-induced immunosuppression. In independent lung, kidney, and bladder cancer patient cohorts, low serum levels of soluble MAdCAM-1 had a negative prognostic impact. Thus, the MAdCAM-1-α4β7 axis constitutes an actionable gut immune checkpoint in cancer immunosurveillance.
2661
Background: In advanced NSCLC, treatment completion at 24 months emerged in trials evaluating immune checkpoint inhibitors (ICI). Nevertheless, in clinical practice the question of the optimal ...treatment duration is under debate. Methods: We performed a retrospective study on advanced NSCLC treated with ICI (alone or with chemotherapy) at Gustave Roussy before 2021. Among patients still receiving ICI at 12 months, we analyzed the reasons for ICI discontinuation at 18 and 24 months. Results: Of the 682 patients treated with ICI (first-line for n=230, 33.7%), 159 (23.3%) received ICI for ≥ 12 months and 122 (17.9%) for ≥ 18 months. Between 18-24 months, 20 (57.1%) patients interrupted ICI for progressive disease (PD), 8 (22.8%) for toxicity and 7 (20.0%) after discussion with the patient. Out of the 88 (12.9%) patients who completed 2-years of ICI (median duration of treatment: 31.46 months, first-line for n=51), 22 (25.0%) patients discontinued ICI for PD and 40 (45.5%) without PD: 14 (15.9%) for toxicities, patient request or unknown causes and 26 (29.5%) for clinical decision before (n=16, 61.5%) or after (n=10, 38.5%) 30 months of treatment. Discontinuation according to phase III clinical trial design was supported by complete response (CR) by PET imaging +/- tissue biopsy of metabolically active lesions +/- ctDNA in 17 (65.4%) cases just before therapy discontinuation. After a median follow-up of 45.6 months since treatment discontinuation for these 26 patients, only two experienced PD at 4 and 6 months from ICI interruption, in both cases with no proof of CR at ICI discontinuation (p=0.111). The remaining 26 (29.5%) patients who continued ICI after 2 years, are on treatment based either on absence of CR at PET-CT +/- tissue biopsy of metabolically active lesions (n=20, 76.9%) or after discussion with the patients (n=6, 23.1%). After a median follow-up of 40.17 months from the of 24-months landmark, the median progression-free survival was unreached in both continuation and discontinuation groups. Conclusions: The patients who completed 2-years of ICI treatment usually continue to experience long‐term response after discontinuation. Considering that a subgroup of patients could still benefit from maintained ICI administration, PET imaging was considered to guide ICI cessation or continuation. Prospective studies specifically designed to investigate biomarkers of maintained responses or residual disease (imaging, ctDNA, multi-omics including microbiome) are required to establish the indication for ICI continuation or stop for each patient.
e16296
Background: Therapeutic resources are often limited in rare tumors. NGS (Next Generation Sequencing) represents a valuable tool that can provide biological and prognostic information and guide ...therapeutic options. Here we describe a case series of the University Hospital of Verona, a center of excellence for neuroendocrine and pancreatic neoplasms. Methods: Between October 2020 and December 2022, 75 patients (pts) with a neuroendocrine neoplasm (NEN) or mixed neuroendocrine non-neuroendocrine neoplasia (MiNEN) underwent NGS analysis with an in-house assay CORE panel (covering 174 genes; 42 pts) or FoundationOne CDx panel (33 pts). We reported ACMG/AMP class IV-V molecular alterations as single nucleotide variations (SNVs), copy number variations (CNVs) including amplifications, deletions, fusions and loss of heterozygosity (LOH). Results: We included 53 well-differentiated neuroendocrine tumors (NETs), 17 poorly differentiated neuroendocrine carcinomas (NECs) and 5 MiNENs. The majority originated from gastro-entero-pancreatic tract (n=67, 89%). The most frequent gene alterations were TP53 (n=30; 12%: 28 SNV and 2 LOH); MEN1 (n=14, 5%: all SNV), CDKN2A (n=12; 5%: 2 SNV, 4 CNV LOH and 5 CNV loss), DAXX (n=12, 5%: all SNV) and RB1 (n=11, 4%: 8 SNV, 4 CNV LOH and 5 CNV loss). In MiNEN pts 3 druggable alterations were found: 1 TRIM-BRAF fusion, 1 SCL4A4-ROS1 fusion and 1 ERBB2 amplification. All MiNENs were MSS; median TMB (mTMB) was 4.86 mut/Mb. Among NET pts the most often altered genes were MEN1 (n=14), DAXX (n=12), TP53 (n=10), PTEN (n=7), CDKN2A (n=5), NF1 (n=5), TSC2 (n=5). The most prevalent mutations in NEC pts involved TP53 (n=17), RB1 (n=9), KRAS (n=7), CDKN2A (n=6), CDKN2B (n=5), CCNE1 (n=5), APC (n=4), SMAD4 (n=3). The mutational rate in NETs was 2.7 with a mTMB of 6.5; the mutational rate in NECs was 5.3 with a mTMB of 7.3 mut/Mb. In NET and NEC 23 actionable mutations were reported. In pancreatic NENs, DAXX mutation was present in 29% of NET G3 and absent in NEC cases. Among G1-G2 NET pts treated with PRRT in 2nd or further lines with a follow-up longer than 60 months (n=17), 6 (35%) were DAXX mutated and all (100%) were still alive at 5 years, compared to 7/11 (64%) in the DAXX wild type (wt) group. Focusing on NET with Ki67% between 3% and 55% (n=45), TP53 wt pts (n=35, 78%) showed a better median overall survival (mOS) than TP53 mutated (n=10, 22%) pts (131.3 vs 56.7 months; p= 0.0433). Conclusions: Our data support the role of NGS in pancreatic rare histologies. This work highlighted the negative prognostic role of TP53 status in G2-G3 NETs, the potential predictive role of DAXX in G1-G2 NET treated with PRRT and its contribution to the differential diagnosis between NET and NEC. Our findings suggest that the pathogenesis in NET is mostly mediated by defects in tumor suppressor genes, while the role of oncogene alterations seem to acquire more importance with increasingly poor differentiation.
Antibiotics (ABX) compromise the efficacy of programmed cell death protein 1 (PD-1) blockade in cancer patients, but the mechanisms underlying their immunosuppressive effects remain unknown. By ...inducing the down-regulation of mucosal addressin cell adhesion molecule 1 (MAdCAM-1) in the ileum, post-ABX gut recolonization by Enterocloster species drove the emigration of enterotropic α4β7 + CD4 + regulatory T 17 cells into the tumor. These deleterious ABX effects were mimicked by oral gavage of Enterocloster species, by genetic deficiency, or by antibody-mediated neutralization of MAdCAM-1 and its receptor, α4β7 integrin. By contrast, fecal microbiota transplantation or interleukin-17A neutralization prevented ABX-induced immunosuppression. In independent lung, kidney, and bladder cancer patient cohorts, low serum levels of soluble MAdCAM-1 had a negative prognostic impact. Thus, the MAdCAM-1–α4β7 axis constitutes an actionable gut immune checkpoint in cancer immunosurveillance.
719
Background: The LIPI score has been reported as an independent prognostic factor in RCC patients treated with immune checkpoint inhibitors (ICI) or tyrosine kinase inhibitors (TKI). Here, we ...aimed to correlate LIPI score and GM composition in patients with RCC. Methods: We prospectively collected fecal samples of all comers RCC patients who started a 1
st
or beyond line therapy (standard or clinical trial) in the NCT0457446 at Gustave Roussy. Neutrophil to lymphocyte ratio (dNLR) and lactate dehydrogenase (LDH) were obtained from routine blood tests. Shot gun metagenomic sequencing (MGS) data were analyzed by multivariate and pair-wise/fold ratio . Clinical benefit ratio (CBR, complete response + partial response + stable disease, RECIST1.1) and overall survival (OS, from treatment start) were evaluated. Multivariate analysis (MVA) for OS included age, gender, therapy line, IMDC, histology, hypoalbuminemia. Results: From February 2016 to July 2021, 160 patients were screened and 102 were included. Median age was 61 years (22-89), patients were mostly males (75%) and clear cell histology (90%). Patients were treated in 1
st
(15%), 2
nd
(53%) and beyond (32%) lines. Treated with ICI monotherapy (65%), followed by TKI or mTOR (20%) and ICI combination (19%). IMDC was 32% good (G), 54% intermediate (I) and 14% poor (P) and LIPI was 69% G, 25% I and 6% P. Median OS was 42.9, 17.7 and 8.3 months in patients with LIPI G, I and P, respectively (p<0.0001) . Among IMDC risk groups, IMDC G + LIPI G had better OS compared to other subgroups (p=0.017), and those with IMDC P + LIPI P had the worse OS. Overall, LIPI G had higher rates of CBR than I+P LIPI (74% vs 50%; p=0.0158). At MVA, LIPI was independently associated with OS (HR 6.25, 2.02-24.34; p=0.0187). Overall, Parabacteroides merdae and Veillonella parvula were enriched in LIPI I+P, while LIPI G harbored Faecalibacterium prausnitzii. In patients treated with ICI monotherapy, LIPI I+P were enriched with Bacteroides spp ( P. merdae, Phocaeicola vulgatus), and LIPI G had an overrepresentation of Ruminococcaceae unclass bacterium. Conclusions: We report the first MGS study correlating LIPI score and GM composition in RCC patients. LIPI score correlates with clinical outcomes (OS and CBR) and helped to better-stratified IMDC risk groups. Patients LIPI G harbor health-related commensals, while I and P groups are associated with harmful ones. LIPI score could represent a clinically relevant score to stratify mRCC patients. Clinical trial information: NCT04567446 .
2572 Background: The gut microbiota influences the cancer immune set point and response to immune checkpoint inhibitors (ICB), participating in the differentiation and function of T cells. We aimed ...to investigate the potential impact of microbiota-specific circulating memory T cells in cancer immunotherapy. Methods: NCT04567446 provided longitudinal blood samples (T0, before starting ICB until 1.5 months; T3, between 3 and 5.5 months) from patients with lung (NSCLC) and kidney (RCC) during ICB therapy (alone or combinations) in France. Different pools of harmful (ENTERO: Enteroclosterspp, Hungatella hathewayi, VEILLEG: Veillonella spp, Eggerthella lenta and KLEBC: Klebsiella pneumoniae, Escherichia coli, Fusobacterium nucleatum (Fn)) or single beneficial (Akkermansia spp. (Akk), Faecalibacterium prausnitzii ( Fp)) pasteurized bacteria (ppB) were used to stimulate whole blood sample (22h). The secretion of CXCL13, IL-17 (ELISA) and IFNg (VIDAS) was quantified at baseline and longitudinally to characterize memory T FH , T H 17 and T H 1 responses, respectively and analyze the effects of antibiotics. Progression-free survival (PFS), overall survival (OS) were assessed according to bacteria-specific T cell responses. Results: From Mar. 2023 to Jan. 2024, a total of 75 patients were screened and 39 patients enrolled in this analysis (54 assessed samples). Median age was 66yr, 72% were male, 74% had NSCLC, 26% had RCC and 78% were treated in first line. Median progression-free survival was 5.3 months (0.9-12.4); median overall-survival was 5.9 months (1.5-12.4). Firstly, we analyzed the 33 samples at baseline. 15% of patients harbored Akk-specific T FH memory responses and those patients with CXCL13 secretion superior to the median of the cohort tended to exhibit longer PFS (p=0.064) while 54% of patients harbored KLEBC T FH memory responses that were clinically irrelevant. 15% of patients harboring circulating Akk-specific T H 1 memory responses had a shorter OS (p=0.055) while VEILLEG or KLEBC-specific T H 1 responses detected in 24% and 42% cases were clinically irrelevant. 26/32 patients who did not show Akk-specific T H 17 responses had a better OS. ATB tended to decrease bacteria-specific CXCL13 and IFNg responses but increased T H 17 memory T cells. While boosting the systemic T H 1 TCR tonus (IFNg secretion by fresh blood T cells stimulated with the positive control (mitogen)), ICB decreased the most prominent reactivities against KLEBC, VEILLEG or Akk, suggesting that bacteria-specific T cells may traffic to tumoral or intestinal locations. Conclusions: Although awaiting further validation and correlations with humoral IgG/A titers, circulating memory T cells against distinct commensals may be clinically relevant to predict benefit to immunotherapy, suggesting that such bacteria may invade tumor cells or share molecular homology with cancer antigens. Clinical trial information: NCT04567446 .
103
Background: Accumulating evidence pointed to the impact of the intestinal microbiota on ICI outcomes across various cancers. Although specific gut microbial species have been associated with ...beneficial responses ( i.e. Akkermansia muciniphila (Akk)), no consensus exists on a gut fingerprint predicting immunoresistance to clinical routine use. Methods: NCT04567446 provided whole genome sequencing (WGS) of longitudinal fecal samples from patients (pts) with advanced non-small cell lung cancer (NSCLC) during ICI (alone or with chemotherapy) in France and Canada. Topological Pearson networks clustered into species interacting groups (SIG) correlating with overall survival (OS; OS<12=NR; OS>12=R). Forty harmful (SIG1) and thirty-four beneficial (SIG2) WGS species were associated with NR and R to ICI. A monodimensional score (TOPOSCORE) based on SIG1/SIG2 ratio combined with Akk relative abundance was calculated and compared to machine-learning (ML) algorithms. Multivariate Cox analysis (MVA) adjusted for established risk factors (ATB, gender, age, ECOG, PD-L1, LIPI score). Intraindividual dynamics of the TOPOSCORE was evaluated in pts with at least two fecal samples. Three independent cohorts of NSCLC and genitourinary (GU) cancers pts validated the data. Results: In n=245 and n=148 NSCLC pts, we could classify pts into dysbiotic (SIG1+,33%) and eubiotic (SIG2+, 67%), using the TOPOSCORE. Pts falling within the SIG2+ exhibited a significantly prolonged OS than pts falling into SIG1+ (HR: (95% CI), 0.50 (0.36-0.71), p<0.0001). TOPOSCORE also predicted OS in 277 ICI-treated NSCLC and GU pts and compared to the state-of-the-art ML algorithms, held the highest percentage of correct predictions (63%). At MVA, TOPOSCORE was independently associated with OS (HR: 0.56 (0.39-0.81), p=0.002). Analyzing the intraindividual dynamics of the TOPOSCORE (n=67), we found that 74% of SIG2+ and 68% of SIG1+ individuals remained in their initial classification during ICI treatment. We finally scaled the calculation of the TOPOSCORE down to 24WGS (instead 75WGS) and set up a qPCR-based friendly-user test capable of accurately identifying the fecal presence of the bacteria of interest within 48 hrs. We confirmed (n=323) that OS was superior in those pts harboring a 24-bacteria-qPCR-based TOPOSCORE falling within the SIG2+ category (HR: 0.65 (0.48 to 0.87), p=0.0005). Conclusions: TOPOSCORE represents a robust biomarker predicting and following the dynamic of the immunoresistance to ICI across cancers on an individual basis. By converting the WGS TOPOSCORE to a qPCR-based test with a rapid turnaround time, it will be possible to adopt this score in routine clinical practice to improve pts stratification and ICI success rates guiding the selection of dysbiotic pts amenable to microbiota-centered interventions and eubiotic fecal microbiota transplantation donors. Clinical trial information: NCT04567446 .
e15065
Background: Next generation Sequencing (NGS) allows the identification of potentially actionable molecular alterations that may constitute a therapeutic opportunity beyond standard systemic ...treatments for advanced cancer patients (pts). The interpretation of NGS profiling and its introduction in clinical practice can be guided by systematic implementation of Molecular Tumor Board (MTB). Methods: Between May 2020 and January 2023, 663 cancer pts accessed NGS profiling, in the context of investigator-driven and/or industry-sponsored research programs, using the CORE panel (in-house developed in collaboration with the International Cancer Genome Consortium - ICGC, covering 174 clinically relevant genes, structural variations and genomic signatures; 411 pts) and commercial FoundationOne CDx or FoundationOne Liquid assays (131 and 27 respectively). Pts with potentially clinically relevant molecular alterations were prescreened by Pathology and Oncology dedicated professionals and within multidisciplinary disease-oriented teams. Here we describe the results of MTB discussions at the Verona University Hospital. Results: Sixty-seven pts (10% of those profiled) were discussed at MTB bi-weekly meetings, between July 2021 and January 2023. Further diagnostic tests were requested in 19 pts (28%; IHC: 7, molecular analyses: 10, re-biopsies: 3). In 1 case histological diagnosis was changed upon re-biopsy (acinar pancreatic cancer to breast cancer NOS). Oncogenetic counselling was proposed in 10 pts (15%). Forty pts (60% of those discussed) were deemed eligible for NGS-informed treatment. Among these, twenty-two pts (55%) did not start MTB-indicated therapy, due to currently non-progressive disease (11), clinical deterioration (7), other Center referral (3) or refusal (1). Eighteen pts (45%) started MTB-recommended therapy in first (17%), second (28%) or > = third line (55%). Treated pts were affected by rare tumors (8), pancreatic cancer (5), NSCLC (2), biliary tract, colon, and breast cancer (1 patient each). Types of treatment were: 12 targeted-, 2 immuno-, 2 chemo-, 2 combined-therapies. Among twelve evaluable pts, one complete response (8%), seven partial responses (58%), two stable (16%) and two progressive diseases (16%) were observed (RECIST v1.1); median PFS in treated pts was 12.7 0.1-17.7 months. Five pts (41%) are currently awaiting response evaluation. Conclusions: Systematic identification and discussion of potentially actionable gene alterations brought to NGS-informed, MTB-endorsed therapeutic indications in 6% of profiled pts, 65% of whom experienced relevant clinical benefit from treatment. Increased and timely (preferably at diagnosis) access to NGS profiling, revised criteria for and more extensive MTB discussions should be implemented to increase the impact of Precision Oncology practices on pts' outcome.
4548
Background: Antibiotics (ATB) deviate the gut taxonomic microbiota composition and have a deleterious impact on survival in ICI-treated pts. ATB downregulate the ileal mucosal addressin cell ...adhesion molecule-1 (MAdCAM-1), leading to the recirculation of immunosuppressive enterotropic T cells into the tumor and ICI resistance. Here, we aimed to assess the prognostic impact of MAdCAM-1 in ICI-treated mRCC pts. Methods: The GETUG-AFU 26 NIVOREN phase II trial (NCT 0301335) is a multicentric study that assessed the activity and safety of Nivolumab in pts with clear cell mRCC after anti-angiogenic therapy. We measured serum soluble MAdCAM-1 (sMAdCAM-1) levels (correlating ileal MAdCAM-1 transcripts) using Human Luminex Discovery Assay in the available plasma. Progression-free survival (PFS), overall survival (OS) and clinical benefit rate (CBR) were assessed using sMAdCAM-1 median as a cut off value (high if >median and low if <median). Multivariate Cox analysis adjusted for established risk factors: ATB, gender, age, international Metastatic RCC Database Consortium (IMDC) score, number of previous lines, hypoalbuminemia, and brain, bone and liver metastasis. Two independent cohorts of metastatic lung and bladder cancer patients validated the data. Results: Overall, 212 pts were included. Median age was 64 years (22-87), and pts were mostly male (82%). ATB users had lower levels of sMadCAM-1. Low sMadCAM-1 pts had diminished OS compared to high sMadCAM-1 pts HR 2.97 (95%CI 1.99-4.44), p<.0001: 13.3 (95%CI 9.8-14.9; 72/106) versus 25.3 (95%CI 24.1-NR; 36/106) months. Also, low sMadCAM-1 pts had diminished PFS HR 1.92 (1.43-2.57), p<.0001: 2.6 (95%CI 2.4-2.8; 99/106) versus 5.2 (95%CI 4.6-5.7; 86/106) months. Interestingly, sMAdCAM-1 was independently associated with OS HR 2.40 (1.52-3.80), p=0.0002 and PFS HR 1.55 (1.13-2.13), p=0.0071 in multivariate analysis. Low sMadCAM-1 pts had lower CBR (37% versus 63%, p=0.0004). Serum sMAdCAM-1 also predicted OS in 381 ICI-treated patients with lung and bladder cancer. Conclusions: Low sMAdCAM-1 is associated with ATB intake, ATB-independent gut dysbiosis and worse outcomes, in ICI-treated pts with metastatic lung, bladder and RCC cancer. ELISA determination of sMAdCAM-1 might guide the selection of patients amenable to microbiota-centered interventions, such as Akkermansia sp., and fecal microbiota transplantation. Clinical trial information: NCT0301335 .
