Faculty Bibliography

Modulating T cell homeostatic mechanisms with checkpoint blockade can efficiently promote endogenous anti-tumor T cell responses^1-11. However, many patients still do not benefit from checkpoint blockade¹², highlighting the need for targeting of alternative immune pathways¹³. Glucocorticoid-induced tumor necrosis factor receptor-related protein (GITR) is an attractive target for immunotherapy, owing to its capacity to promote effector T cell (T_eff) functions^14,15 and hamper regulatory T cell (T_reg) suppression^16-20. On the basis of the potent preclinical anti-tumor activity of agonist anti-GITR antibodies, reported by us and others^16,21,22, we initiated the first in-human phase 1 trial of GITR agonism with the anti-GITR antibody TRX518 ( NCT01239134 ). Here, we report the safety profile and immune effects of TRX518 monotherapy in patients with advanced cancer and provide mechanistic preclinical evidence to rationally combine GITR agonism with checkpoint blockade in future clinical trials. We demonstrate that TRX518 reduces circulating and intratumoral T_reg cells to similar extents, providing an easily assessable biomarker of anti-GITR activity. Despite T_reg reductions and increased T_eff:T_reg ratios, substantial clinical responses were not seen. Similarly, in mice with advanced tumors, GITR agonism was not sufficient to activate cytolytic T cells due to persistent exhaustion. We demonstrate that T cell reinvigoration with PD-1 blockade can overcome resistance of advanced tumors to anti-GITR monotherapy. These findings led us to start investigating TRX518 with PD-1 pathway blockade in patients with advanced refractory tumors ( NCT02628574 ).

Even in diffuse large B-cell lymphoma (DLBCL), a cancer of professional antigen-presenting cells, response rates to immune checkpoint blockade therapy have been limited. One reason for DLBCL immune evasion is epigenetic repression instead of activation of the antigen-presenting MHC-a dissection of mechanisms underlying this repression suggests an opening for restoring B-cell maturation and, along the way, MHC expression as a novel modality of cytoreducing DLBCL and simultaneously augmenting possibilities for immunotherapy.See related article by Ennishi et al., p. 546.

Purpose/UNASSIGNED:response to chemotherapy in patients with non-small cell lung cancer (NSCLC). Materials and Methods/UNASSIGNED:Data in a total of 125 patients who had been treated with pemetrexed-based platinum doublet chemotherapy at Cleveland Clinic were retrospectively analyzed. The patients were divided randomly into two sets with the constraint that there were an equal number of responders and nonresponders in the training set. The training set comprised 53 patients with NSCLC, and the validation set comprised 72 patients. A machine learning classifier trained with radiomic texture features extracted from intra- and peritumoral regions of non-contrast-enhanced CT images was used to predict response to chemotherapy. The radiomic risk-score signature was generated by using least absolute shrinkage and selection operator with the Cox regression model; association of the radiomic signature with TTP and OS was also evaluated. Results/UNASSIGNED:= .0011). Additionally, decision curve analysis demonstrated that in terms of clinical usefulness, the radiomics signature had a higher overall net benefit in prediction of high-risk patients to receive treatment than the clinicopathologic measurements. Conclusion/UNASSIGNED:

BACKGROUND:Small cell lung cancer (SCLC) accounts for 10-15% of all lung malignancies and its prognosis is dismal. Although early studies have shown promising clinical activity of immune checkpoint blockers, the immune composition and expression of potentially actionable immunostimulatory targets in this malignancy are poorly understood. METHODS:Using multiplexed quantitative immunofluorescence (QIF), we measured the levels of 3 different B7 family ligands PD-L1, B7-H3, B7-H4 and major tumor infiltrating lymphocyte (TIL) subsets in 90 SCLC samples represented in tissue microarray format. Associations between the marker levels, clinicopathological variables and survival were studied. RESULTS:PD-L1 protein was detected in 7.3%, B7-H3 in 64.9% and B7-H4 in 2.6% of SCLC cases. The markers showed limited co-expression and were not associated with the level of TILs, age, gender and stage. Elevated B7-H4 was associated with shorter 5-year overall survival. The levels of CD3+, CD8+ and CD20+ TILs and the ratio of total/effector T-cells were significantly lower in SCLC than in non-small cell lung cancer. High levels of CD3+, but not CD8+ or CD20+ TILs were significantly associated with longer survival. CONCLUSIONS:Taken together, our study indicate variable expression and clinical role of B7-family ligands in SCLC with predominant expression of the candidate target B7-H3 and the presence of a limited cytotoxic anti-tumor immune response. These results support the evaluation of B7-H3 blockers and/or pro-inflammatory therapies in SCLC.

PURPOSE/OBJECTIVE:Presence of a high degree of tumor-infiltrating lymphocytes (TILs) has proven to be associated with outcome in patients with non-small cell lung cancer (NSCLC). However, recent evidence indicate that tissue architecture is also prognostic of disease specific survival and recurrence. We show a set of descriptors (SpaTIL) that capture density and spatial co-localization of TILs and tumor cells across digital images can predict likelihood of recurrence in early-stage NSCLC. EXPERIMENTAL DESIGN/METHODS:; intra-observer agreement and association between manual grading and likelihood of recurrence were analyzed. RESULTS:). CONCLUSION/CONCLUSIONS:A set of features related to density and spatial architecture of TILs was found to be associated with a likelihood of recurrence of early-stage NSCLC. This information could potentially be used for helping in treatment planning and management of early-stage NSCLC.

Purpose To evaluate ability of radiomic (computer-extracted imaging) features to distinguish non-small cell lung cancer adenocarcinomas from granulomas at noncontrast CT. Materials and Methods For this retrospective study, screening or standard diagnostic noncontrast CT images were collected for 290 patients (mean age, 68 years; range, 18-92 years; 125 men [mean age, 67 years; range, 18-90 years] and 165 women [mean age, 68 years; range, 33-92 years]) from two institutions between 2007 and 2013. Histopathologic analysis was available for one nodule per patient. Corresponding nodule of interest was identified on axial CT images by a radiologist with manual annotation. Nodule shape, wavelet (Gabor), and texture-based (Haralick and Laws energy) features were extracted from intra- and perinodular regions. Features were pruned to train machine learning classifiers with 145 patients. In a test set of 145 patients, classifier results were compared against a convolutional neural network (CNN) and diagnostic readings of two radiologists. Results Support vector machine classifier with intranodular radiomic features achieved an area under the receiver operating characteristic curve (AUC) of 0.75 on the test set. Combining radiomics of intranodular with perinodular regions improved the AUC to 0.80. On the same test set, CNN resulted in an AUC of 0.76. Radiologist readers achieved AUCs of 0.61 and 0.60, respectively. Conclusion Radiomic features from intranodular and perinodular regions of nodules can distinguish non-small cell lung cancer adenocarcinomas from benign granulomas at noncontrast CT. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Nishino in this issue.

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment paradigms for a broad spectrum of malignancies. Because immune checkpoint inhibitors rely on immune reactivation to eliminate cancer cells, they can also lead to the loss of immune tolerance and result in a wide range of phenomena called immune-related adverse events (irAEs). At our institution, the management of irAEs is based on multidisciplinary input obtained at an irAE tumor board that facilitates expedited opinions from various specialties and allows for a more uniform approach to these patients. In this article, we describe a case of a patient with metastatic urothelial carcinoma who developed a maculopapular rash while being treated with a programmed death-ligand 1 inhibitor. We then describe the approach to management of dermatologic toxicities with ICIs based on the discussion at our irAE Tumor Board. KEY POINTS: Innocuous symptoms such as pruritis or a maculopapular rash may herald potentially fatal severe cutaneous adverse reactions (SCARs); therefore, close attention must be paid to the symptoms, history, and physical examination of all patients.Consultation with dermatology should be sought for patients with grade 3 or 4 toxicity or SCARs and prior to resumption of immune checkpoint inhibitors for patients with grade 3 or higher toxicity.A multidisciplinary immune-related adverse events (irAE) tumor board can facilitate timely input and expertise from various specialties, thereby ensuring a streamlined approach to management of irAEs.

Background Regulatory T cells (Tregs) mediate potent tolerogenic signals, are involved in adaptive anti-tumor immune responses and T-cell reinvigoration using immune checkpoint blockers. Despite their prominent immune suppressive role, the tissue distribution and contribution of Tregs to clinical outcomes in human lung cancer is not well understood. Methods The levels and tissue distribution of Tregs and major tumor infiltrating lymphocyte (TIL) subsets were measured using simultaneous detection of FOXP3, CD4, CD8, pancytokeratin and DAPI by multiplexed quantitative immunofluorescence in 619 formalin-fixed paraffin embedded (FFPE) NSCLCs from 4 independent cohorts represented in tissue microarrays (cohort#1 [Yale, n=210], cohort#2 [Greece, n=192]; cohort#3] [80 immunotherapy-treated NSCLCs]; cohort#4 [Yale, n=137, adenocarcinomas with mutation testing). Markers were measured in different tissue compartments and cell phenotypes were used for individual cell counts and machine-learning-based spatial analysis. We studied the association between T-cell populations, tissue distribution, clinicopathologic/ molecular characteristics and outcomes. Results Tregs (DAPI+/CD4+/FOXP3+ cells) were predominantly located in the stromal compartment and represented 3-10% of the total T-cell population. The level of Tregs was positively associated with higher CD8+ Tcell infiltration across the cohorts. There was no consistent association between Treg levels and patient age, gender, smoking status, clinical stage or tumor histology. However, Tregs were significantly higher in KRAS mutated lung adenocarcinomas than in EGFR mutant or KRAS/ EGFR wild-type cases. As a single marker, the level of Tregs was not significantly associated with survival. However, the Treg to CD8 signal ratio was associated with shorter 5-year overall survival across the cohorts. Reduced survival was also seen in cases with a higher 5-nearest neighbor (5NN) mean distance between CD4+/Tregs and CD8+/CD4+ cells. Notably, the survival effect of the Treg-associated metrics was numerically higher in patients treated with immune checkpoint blockers. Conclusions Tregs are prominently less abundant than other TIL subsets in NSCLC microenvironments and they are increased in T-cell inflamed tumors. Their positive association with CD8+ cytotoxic TILs suggests their upregulation upon adaptive anti-tumor immune pressure and could explain the inconsistent reported relationship between Tregs and prognosis. Elevated Treg to CD8 signal ratio and reduced spatial clustering between CD4-Tregs and CD8-CD4 are indicative of poor outcome preferentially in NSCLC patients treated with checkpoint blockade suggesting a biomarker role