Immune checkpoint inhibitors (ICIs) have transformed the management of advanced renal cell carcinoma (RCC), but most patients still do not receive a long-term benefit from these therapies, and many ...experience off-target, immune-related adverse effects. RCC is also different from many other ICI-responsive tumors, as it has only a modest mutation burden, and total neoantigen load does not correlate with ICI response. In order to improve the efficacy and safety of immunotherapies for RCC, it is therefore critical to identify the antigens that are targeted in effective anti-tumor immunity. In this review, we describe the potential classes of target antigens, and provide examples of previous and ongoing efforts to investigate and target antigens in RCC, with a focus on clear cell histology. Ultimately, we believe that a concerted antigen discovery effort in RCC will enable an improved understanding of response and resistance to current therapies, and lay a foundation for the future development of “precision” antigen-directed immunotherapies.
The coronavirus disease 2019 pandemic has led to global disruption of healthcare. Many students volunteered to provide clinical support. Volunteering to work in a clinical capacity was a unique ...medical education opportunity; however, it is unknown whether this was a positive learning experience or which volunteering roles were of most benefit to students.
The COVIDReady2 study is a national cross-sectional study of all medical students at medical schools in the United Kingdom. The primary outcome is to explore the experiences of medical students who volunteered during the pandemic in comparison to those who did not. We will compare responses to determine the educational benefit and issues they faced. In addition to quantitative analysis, thematic analysis will be used to identify themes in qualitative responses.
There is a growing body of evidence to suggest that service roles have potential to enhance medical education; yet, there is a shortage of studies able to offer practical advice for how these roles may be incorporated in future medical education. We anticipate that this study will help to identify volunteer structures that have been beneficial for students, so that similar infrastructures can be used in the future, and help inform medical education in a non-pandemic setting.
Not Applicable.
BackgroundRenal cell carcinoma (RCC) is an immunologically paradoxical tumor. Despite high T cell infiltration, increased CD8+ T cells are not associated with response to programmed cell death 1 ...(PD-1) blockade.1 Through single-cell transcriptomic analysis, we previously identified a population of SLAMF7+ CD8+ exhausted T cells that was associated with resistance to nivolumab monotherapy in the HCRN GU16–260 trial (NCT03117309) (Braun, ASCO, 2023). In the present study, we generated a gene expression signature (GES) to capture the proportion of this SLAMF7+ T cell population and investigated the association of this GES with clinical outcomes in an external RCC cohort, CheckMate-025.1 MethodsFor each gene in our bulk RNA sequencing (RNA-seq) expression matrix, we determined the Spearman correlation between the gene’s normalized expression level and the proportion of SLAMF7+ CD8+ T cells in patients with matched single cell (scRNA-seq) and bulk RNA-seq data (n = 7). Following z-scoring of all genes, we calculated the average expression of the twenty genes with the highest Spearman correlation coefficient to generate a GES score for all samples without matched scRNA-seq data in the HCRN GU16–260 cohort (n = 85). Both correlation and GES scoring included samples of clear cell and non-clear cell histology. GES scoring was repeated separately for patients receiving anti-PD1 monotherapy (nivolumab; n = 172) or mTOR inhibitor (everolimus; n = 109) monotherapy in the CheckMate-025 cohort.ResultsPatients with progressive disease (PD) had higher GES scores than those with complete/partial response (CR/PR) in both HCRN GU16–260 (p=0.027) and the nivolumab arm of the CheckMate-025 (p=0.0058) cohort. Similarly, high ( ≥ median) scores were associated with worse progression free survival (PFS) (HCRN p=0.045, HR 95% CI =1.72 1.02–2.9; CheckMate-025 nivolumab p=0.03, HR 95% CI =1.62 1.07–2.46) in these cohorts. The same patterns were observed in clear cell and non-clear cell subsets of the HCRN GU16–260 cohort. Conversely, for the everolimus arm of CheckMate-025, there were no differences in scores between PD and CR/PR groups (p=0.4) or association with PFS (p=0.81, HR 95% CI = 1.06 0.65–1.74).ConclusionsWe present a GES characteristic of SLAMF7+ CD8+ exhausted T cells that is associated with worse clinical outcomes in patients receiving anti-PD1 monotherapy, but not in patients receiving mTOR inhibitor monotherapy. Future work will aim to validate our findings in additional external RCC cohorts, examine the applicability of our findings to additional cancer types, and experimentally interrogate the impact of SLAMF7 signaling on CD8+ T cell function.ReferenceBraun DA, Hou Y, Bakouny Z, et al. Interplay of somatic alterations and immune infiltration modulates response to PD-1 blockade in advanced clear cell renal cell carcinoma. Nat Med. 2020;26:909–918.
ANEC was initially described in 1995 as encephalopathy associated with hyperpyrexia, raised CSF protein and symmetrical necrotic lesions in the thalami and brainstem. 1 There is an association with ...upper respiratory tract illnesses, particularly influenza A. 2 3 It has significant morbidity and mortality. 4 5 Evidence regarding optimal therapy is limited; however, early steroids and immunoglobulin is associated with improved outcome. 5 Most children experience a monophasic illness but predisposition to recurrent episodes is associated with mutations in the RAN binding protein 2 (RANBP2) gene. 3 5 It is unclear whether this gene affects outcome.
The tumor immune microenvironment plays a critical role in cancer progression and response to immunotherapy in clear cell renal cell carcinoma (ccRCC), yet the composition and phenotypic states of ...immune cells in this tumor are incompletely characterized. We performed single-cell RNA and T cell receptor sequencing on 164,722 individual cells from tumor and adjacent non-tumor tissue in patients with ccRCC across disease stages: early, locally advanced, and advanced/metastatic. Terminally exhausted CD8+ T cells were enriched in metastatic disease and were restricted in T cell receptor diversity. Within the myeloid compartment, pro-inflammatory macrophages were decreased, and suppressive M2-like macrophages were increased in advanced disease. Terminally exhausted CD8+ T cells and M2-like macrophages co-occurred in advanced disease and expressed ligands and receptors that support T cell dysfunction and M2-like polarization. This immune dysfunction circuit is associated with a worse prognosis in external cohorts and identifies potentially targetable immune inhibitory pathways in ccRCC.
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•scRNA-seq defines the infiltrating immune populations in ccRCC across disease stages•Terminally exhausted CD8+ T cells and M2-like TAMs are enriched in advanced ccRCC•Exhausted CD8+ T cells and TAMs interact to form an immune dysfunction circuit•Signature of terminal exhaustion/TAM interaction is associated with worse prognosis
The immune cell changes that occur with advancing disease stage in renal cell carcinoma are incompletely characterized. Braun et al. show that terminally exhausted CD8+ T cells and M2-like tumor-associated macrophages are enriched in advanced disease and interact to form an immune dysfunction circuit that is associated with poorer prognosis.
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Background: Nivo monotherapy demonstrated anti-tumor activity in treatment-naïve RCC in Part A of HCRN GU16-260 across all IMDC groups and in multiple histologies. Patient tumor samples were ...collected to characterize the tumor-immune microenvironmental determinants of effective anti-tumor immunity with nivo. Methods: Whole exome sequencing (WES) was performed on formalin-fixed, paraffin-embedded tissue collected within one year prior to nivo. For single-cell RNA-sequencing (scRNA-seq), eligible patients (pts) with any RCC histology underwent tumor biopsy prior to and/or at resistance to nivo monotherapy. Gene expression signatures discovered through scRNA-seq were used to interrogate previously published bulk transcriptomic data of nivo in the treatment-refractory setting. Results: WES analysis (n = 96 tumors) identified recurrent focal amplifications within chromosome 11q13 (amp11q13), which was observed in 6 of 18 (33.3%) of tumors from pts with progressive disease (PD) compared to 0 of 20 (0%) of tumors from pts with complete or partial response (CR/PR; p = 0.005). amp11q13 was associated with worse progression free survival (PFS; p = 0.008) and overall survival (OS; p = 0.010). ScRNA-seq was performed on tumors from 17 pts (8 with baseline only, 7 with progression only, and 2 with paired baseline and progression samples) across 7 trial sites. Trajectory inference analysis of tumor-infiltrating T cells revealed a bifurcating structure, starting with naïve T cells and ending either in terminally exhausted CD8+ T cells or SLAMF7+ CD8+ T cells. Surprisingly, the SLAMF7+ T cell population expressed high levels of cytotoxic genes (including GZMA, GZMB, GNLY) and markers of tissue residency ( ZNF683/HOBIT and ITGAE/CD103). Of the 14 pts with at least 100 sequenced tumor-infiltrating T cells, the presence of a higher percentage of SLAMF7+ CD8+ T cells (relative to total T cells) was associated with primary resistance to nivo (mean percentage in PD n = 4 pts 32.7%; stable disease n = 4 pts, 9.1%; CR/PR n = 6 pts, 2.2%; p = 0.019 for CR/PR vs PD). Of 172 pre-treatment tumors from the nivo arms of the CheckMate-009/010/025 trials that we analyzed by bulk RNA-seq, a signature score derived using genes expressed in the SLAMF7+ CD8+ T cell trajectory branch was enriched in pts with PD compared to CR/PR as best response (p = 0.032). Conclusions: Bulk genomic and single-cell transcriptomic analyses uncovered somatic alterations (amp11q13) and infiltrating T cell populations ( SLAMF7+ CD8+) associated with resistance to frontline nivo monotherapy in a phase II study in RCC. Additional independent and functional validation studies are in progress.
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Background: Nivolumab (nivo) monotherapy demonstrated anti-tumor activity in treatment-naïve renal cell carcinoma (RCC) in Part A of HCRN GU16-260 across all IMDC groups and in multiple ...histologies. Patient tumor samples were collected to characterize the tumor-immune microenvironmental (TME) determinants of effective anti-tumor immunity with nivo. Methods: Eligible patients (with clear cell or non-clear cell histology) underwent tumor biopsy prior to and/or at resistance to nivo monotherapy. Fresh tissue fragments were cryopreserved locally and centrally processed to extract viable single-cells from the RCC TME. Single-cell RNA-sequencing (scRNA-seq) and T cell receptor (TCR)-sequencing (scTCR-seq) was performed on all tumor samples. Gene expression signatures discovered through scRNA-seq were used to interrogate previously published bulk transcriptomic data from the CheckMate-009/010/025 trials of nivo in the treatment-refractory setting. Results: In total, 72,730 viable single-cells (56,900 immune and 15,830 tumor or stromal cells) were sequenced from 17 patients (8 with baseline only, 7 with progression only, and 2 with paired baseline and progression samples) across 7 trial sites. Trajectory inference analysis of tumor-infiltrating T cells revealed a bifurcating trajectory, starting with naïve T cells and ending either in PMCH+ terminally exhausted CD8+ T cells or SLAMF7+ CD8+ T cells. Notably, the SLAMF7+ T cell population expressed high levels of cytotoxic genes (including GZMA, GZMB, GNLY) and markers of tissue residency ( ZNF683/HOBIT and ITGAE/CD103), and had a restricted TCR diversity (normalized Shannon index = 0.57). Among patients with at least 100 sequenced T cells (n = 14), a higher percentage of SLAMF7+ CD8+ T cells (relative to total T cells) was associated with primary resistance (progressive disease PD as best response) to nivo (mean percentage in PD n = 4 patients 32.7%; stable disease n = 4 patients, 9.1%; complete or partial response CR/PR; n = 6 patients, 2.2%; p = 0.019 for CR/PR vs PD). A signature derived using genes expressed in the T cell trajectory branch containing the SLAMF7+ CD8+ T cell population was used to interrogate bulk RNA-seq data from 172 pre-treatment tumors from the nivo arms of the CheckMate-009/010/025 trials. The signature score was enriched in patients with PD compared to CR/PR as best response (p = 0.032). Analysis of bulk whole exome sequencing and RNA-seq from patients enrolled in the HCRN GU16-260 is pending. Conclusions: Single-cell transcriptomic analysis uncovered a SLAMF7+ CD8 + T cell population with markers of cytotoxicity and tissue residency that was associated with resistance to nivo monotherapy in RCC. Further, the study highlights that scRNA-seq is a viable scientific strategy for deep correlative analysis in multicenter clinical trials.
4515 Background: RCC is notable for a high CD8+ T cell infiltration despite its modest tumor mutational load. However, CD8+ T cell infiltration does not correlate with ICI response, highlighting the ...need to understand cellular composition and phenotype. We conducted a comprehensive dissection of the tumor microenvironment (TME) using pre- and post-ICI treatment samples to identify specific T-cell populations associated with ICI treatment efficacy in RCC. Methods: A total of 70 tumor samples (n = 59 clear cell; n = 11 non-clear cell) from 63 patients with RCC were collected before (n = 48) and/or after (n = 22) systemic therapies (VEGFi, n = 9; mono-ICI, n = 20; ICI + ICI, n = 17; ICI + VEGFi, n = 9; others, n = 15). This cohort contained 12 paired samples on pre and post from 5 patients, and 58 unpaired samples. Responders (R) were defined as complete and partial responses (n = 22), and non-responders (NR) as disease progression (n = 33) according to the best response based on RECIST. We performed single-cell RNA-sequence (scRNA-seq) on all samples and established a transcriptomics atlas in RCC. We utilized established gene expression signatures to interrogate cellular composition and functional states for samples from ICI-treated patients. We used non-negative matrix factorization (NMF) to identify gene programs, offering superior feature preservation and interpretability. Results: 443,337 high-quality viable cells were annotated to lymphoid, myeloid, tumor, endothelial, or fibroblast compartments, capturing the RCC TME landscape. Among CD8+ T cells, we observed significant heterogeneity, particularly in exhausted T cells (Tex) expressing PD-1 and TIM-3. Tex in NR showed enrichment for tissue-residency and innate-like genes and gene programs, exemplified by significant upregulation of ZNF683 (p = 0.031) and ITGAE (p = 0.0041). In contrast, Tex in R exhibited a marked upregulation of heat shock protein genes, such as HSP1B (p < 2.22E-16) and DNAJB1 (p < 2.22E-16), highlighting a distinct genomic profile. Notably, through NMF analysis, Tex in R showed a significantly higher stress response program and terminal exhaustion program than in NR at baseline and after ICI treatment. Further analysis through gene signature scoring showed an association between Tex in R and enhanced IFN and chemokine activities, stress response, and terminal differentiation post-ICI. Conclusions: Our single-cell transcriptomic analysis uncovered the relationship between Tex with active stress responses and ICI efficacy, additional suggesting T cell revival with ICI-exposure. This study identifies the specific Tex characteristics associated with ICI responsiveness, highlighting scRNA-seq as a scientific strategy for deep correlative analysis in large patient cohorts, and emphasizing the need for further investigation into the unique intricacies of the RCC TME.
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Background: ChRCC is a rare form of kidney cancer with a poor prognosis in the metastatic setting, in part due to very limited responses to immune checkpoint inhibitors (ICIs), as compared to ...clear cell RCC (ccRCC). The mechanisms underlying the poor response of ChRCC to ICIs remain largely uncharacterized. We therefore investigated at the single-cell resolution the cellular and molecular determinants of anti-tumor immunity in ChRCC. Methods: ChRCC samples with matched normal kidney specimens were evaluated using single-cell RNA (scRNA-seq) and single-cell T-cell receptor (scTCR-seq) sequencing. Similar data (scRNA-seq and scTCR-seq) was obtained for ccRCC samples (Braun DA. et al., 2021). T cell clonotypes were inferred and classified into their degree of expansion (poorly, moderately and highly expanded). Diversity metrics (normalized Shannon’s entropy) were calculated. Using a previously described methodology (Young M.D. et al., 2018), the cell of origin (COi) of ChRCC was inferred from scRNA-seq data of normal kidney samples, followed by differential gene expression (DGE) and pathway analysis (DPA) between the putative COi and ChRCC cells to identify potential mediators of diminished immune responses. Immunohistochemistry (IHC) of ChRCC and ccRCC samples was used to assess CD8+ and PD-1+ immune cell populations. Results: Analysis of the scTCR-seq data identified a higher proportion of poorly expanded clonotypes in ChRCC as compared to ccRCC (p=0.05), along with a lower proportion of highly expanded clonotypes (p=0.07). Normalized (Shannon’s) entropy was found to be higher in ChRCC versus ccRCC (p<0.05). Analysis of annotated scRNA-seq data identified a lower proportion of CD8+ and CD4+ T-cells among immune cells in ChRCC vs. ccRCC (44.6 vs. 9.6% and 12.3 vs. 3.2%, respectively). DGE between ChRCC and its putative COi (alpha-intercalated cell) showed a lower expression of HLA class I genes in ChRCC (p<0.05). DPA showed a marked downregulation of antigen presentation and protein processing pathways in ChRCC (p<0.05). IHC analysis showed a markedly low infiltration of CD8+ and PD-1+ immune populations in ChRCC, as compared to ccRCC. Conclusions: ChRCC cells have marked downregulation of HLA class I genes and antigen processing pathways related to their COi. Additionally, ChRCC tumors have poor infiltration of T-cells, which show a low degree of clonal expansion. These mechanisms may help to explain the limited anti-tumor immunity and ultimately, the poor response to ICIs seen among patients with ChRCC.
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Background: ChRCC is an uncommon kidney cancer variant that has a poor prognosis in the metastatic setting, with limited response to current standard-of-care immune checkpoint inhibitors (ICIs) ...used for other RCC histologies. We evaluated the tumor-immune microenvironment of ChRCC and other related oncocytic neoplasms to better understand the immunophenotype of these tumors. Methods: We performed paired single-cell RNA sequencing (scRNA-seq), single-cell T-cell receptor sequencing (scTCR-seq), and CD45 immunohistochemistry (IHC) of ChRCC, renal oncocytoma (RO) and low-grade oncocytic tumor (LOT) tumor and matched normal samples. Bulk RNA-sequencing (RNA-seq) data of clear cell RCC (ccRCC), papillary RCC (pRCC) and ChRCC were additionally analyzed using The Cancer Genome Atlas (TCGA) kidney cancer cohorts. T cell antigenic specificities from scTCR-seq were inferred using a comprehensive database of annotated T-cell receptor sequences (VDJdb). Single-cell transcriptomic signatures were used to infer the tumor specificity (Oliveira G, Nature, 2021 and Lowery FJ, Science, 2022) and viral specificity (Oliveira G, Nature, 2021) of CD8+ T-cells from ChRCC, as compared to those from ccRCC (Braun DA, Cancer Cell, 2021). Results: ChRCC and other oncocytic tumors had a lower infiltration of CD45+ immune cells as compared to ccRCC (p<0.01). Single-cell analysis was performed on 46,817 cells from 5 tumors (ChRCC: n=3, RO: n=1 and LOT: n=1) and 4 normal samples. Across all tumors, CD8+ T cell clusters displayed a lower expression of immune checkpoints (i.e. PDCD1 PD-1, CTLA4, LAG3, HAVCR2 TIM-3, and TIGIT) as compared to ccRCC. This was further validated in a bulk RNA-seq analysis using TCGA data, with a significantly lower expression of all immune checkpoints in ChRCC compared to both ccRCC (p<0.01) and papillary RCC (pRCC; p<0.01). Analysis of the T cell receptor repertoire (scTCR-seq) of ChRCC, RO and LOT samples did not show any pattern of clonal expansion, and a higher proportion of T cells in ChRCC were inferred to have a viral specificity, as compared to ccRCC (0.79 vs. 0.1%, respectively). CD8+ T cells from ChRCC (vs. ccRCC) displayed a significantly lower expression of two signatures of tumor specificity (p<0.01), and a higher expression of the viral-specific signature (p<0.01). Conclusions: In ChRCC, there is low infiltration by CD45+ immune cells. Although infiltrating CD8+ T cells have a predominantly non-exhausted immune phenotype, they likely lack anti-tumor specificity (i.e. are “bystander” T cells). These findings may help to understand the molecular basis for the lack of response to immunotherapy recently identified among patients with advanced ChRCC, and support future therapeutic strategies to increase infiltration of tumor-specific T cells into the tumor microenvironment.
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