Faculty Bibliography

The multinational phase 3 CheckMate 238 trial compared adjuvant therapy with nivolumab versus ipilimumab among patients with resected stage III or IV melanoma (N = 906). In this Japanese subgroup analysis of CheckMate 238 (n = 28; nivolumab, n = 18; ipilimumab, n = 10), both the 12- and 18-month recurrence-free survival rates were 56% for nivolumab and 30% for ipilimumab (hazard ratio, 0.66; 97.56% confidence interval, 0.19-2.24; P = 0.4390). No new safety signals were reported for Japanese patients. Results were consistent with those from the CheckMate 238 global population, indicating that nivolumab has the potential to be a treatment option for Japanese patients with resected melanoma who are at high risk of recurrence.

Background Nivolumab and ipilimumab (ipi) combination immunotherapy has a ~60% response rate in metastatic melanoma patients. However, the impact of these therapies on immune cell phenotypes and the relationship of those changes to patient outcomes remains under-investigated. Methods High dimension flow cytometry on baseline and at week 13 (e.g. after initial nivo or ipi therapy) was performed for peripheral blood samples from 33 metastatic melanoma patients receiving sequential nivo-ipi or the reverse sequence. We used a novel computational approach to analyze the data through semi-comprehensive Boolean gating in which immune cell lineages (e.g. CD3+CD4+) were evaluated for all possible combinations for up to 15 markers. Results 3,844 measured immunophenotypes were significantly altered post-nivo, and 7,133 immunophenotypes were altered post-ipi. The frequency of 584 immunophenotypes were significantly changed in both treatments, with 59 of those changing in opposing directions. In the nivo-ipi cohort, 260 baseline and 662 post-nivo immunophenotypes were significantly associated with response and survival (outcomes). In the ipi-nivo cohort, 432 baseline and 668 post-ipi immunophenotypes were associated with outcomes. Two highly similar immunophenotypes associated with outcomes overlapped between the cohorts, CD14⁺CD11C+CD33+CD15-CD19-PDL1- PDL2+CD163+GAL9-CD80-CD86-41BBL+CD40+OX40L+ cells. While lower levels of these cells were associated with response and improved survival in nivo-ipi treated patients, lower levels were associated with better outcomes in the ipi-nivo treated patients. Of the 3,844 immunophenotypes altered post-nivolumab, 100 were also associated with ipi-nivo response. Of these 100, 97% were altered in a manner positively associated with response (e.g. upregulated by nivolumab and higher in responders). For example, nivo upregulated CD4+CD45RO-CCR7+ frequencies, which were associated with response and longer survival in ipi-nivo treated patients. Of the 7,133 immunophenotypes altered post-ipi, 110 were also associated with nivo-ipi response. Of these, 95% were altered in a manner negatively associated with response. This includes ipi associated upregulation of a population of CD4+CD38+CD39+CD127-GARP- cells that are negatively associated with coutcomes in nivo-ipi treated patients as well as downregulation of a CD4+CD127+CD45RO+CD95+CCR7+ population of cells positively associated with outcomes. Conclusions These results demonstrate that nivo and ipi altered the peripheral immune landscape in distinct ways. While immunophenotypic changes post-nivo favored response in ipi-nivo treated patients, changes associated with ipi treatment favored progression with ipi-nivo. These data suggest that the immunophenotypic impact of ipi alters the immune landscape in a manner that may impair a subsequent response to nivo. These data also highlight several novel immune cell populations that are associated with both treatment effects and patient outcomes

Background Therapies targeting T-cell co-inhibitory molecules (e.g. PD1) have demonstrated unprecedented efficacy in the treatment of metastatic melanoma. However, not all patients respond to checkpoint inhibition, so there is an unmet need to identify mechanisms of resistance/response. Methods Using IsoLight, a platform for assessing the secretion of 32 analytes at single-cell resolution, we evaluated previously frozen peripheral blood T-cells from six responding and six progressing patients (according to RECIST 1.1 criteria) treated with nivolumab. Baseline and week 13, post-treatment CD4+ and CD8+ T-cell samples were assessed for each patient. T-cells were stimulated with CD3 and CD28 activating antibodies overnight and subsequently placed on capture chips for 20 hours. Approximately 400 single-cell events were assessed for each sample. Results CD4+ T-cells from progressing patients, compared to those from responding patients, had significantly (p<0.05) higher mean production of IL-17F post-nivolumab and an increased proportion of cells secreting IL-13, RANTES, IL-6, soluble CD137, TNF, MIP1a and MIP1b relative to baseline. Using an elastic net machine learning algorithm with cross validation, we assessed the ability of a manually curated list of analytes to predict patient outcomes. Delta values (post-treatment minus baseline values) were used for 15 parameters. A receiver operating characteristic with an area under the curve of 0.898 was achieved. The most important features in these models were the percentage of CD4+ T-cells expressing IL-6, MIP1a and soluble CD137 along with the percentage of CD8+ T-cells expressing IL-13. Conclusions These results demonstrate the ability of single-cell, high-dimension technologies coupled with machine learning to reveal complex associations between immune cell function and clinical outcomes. Specifically, these data show that changes in secretome production potential of T-cells after treatment with the PD1 blocking antibody nivolumab are associated with metastatic melanoma patient outcomes. We identified a signature of secreted molecules that were associated with patient outcomes, providing rationale for targeting these molecules to increase the efficacy of nivolumab. Work is underway to validate the observed associations in an independent set of patient samples

Background Siglec-15 (S15) is a member of the Siglec family (Sialic acidbinding Immunoglobulin Lectins), a distinct subgroup of immunoglobulin (Ig) superfamily proteins involved in discriminating self and non-self-immune regulation [1]. Recent studies have shown that S15 mediates suppression of T cell proliferation and negatively regulates T cell function. The expression of S15 and PD-L1 are mutually exclusive in NSCLC and other cancers, which supports S15 as a potential target for the treatment of cancer patients who are refractory to PD-1 directed therapies. NC318 is a first-in-class monoclonal antibody that blocks S15-mediated immune suppression and prevents tumor growth by normalizing T cell function and restoring anti-tumor immunity in the tumor microenvironment [2]. Methods NC318-01 is a multi-center, first-in-human, phase 1/2, open-label, non-randomized study to determine the safety and tolerability, define the maximum tolerated dose or pharmacologically active dose, and assess the preliminary efficacy of NC318. The phase 1 component uses a 3+3 dose escalation design to determine the recommended phase 2 dose (RP2D) of NC318. Primary endpoints include safety and tolerability. Secondary endpoints include assessment of pharmacokinetics, response rate (measured every 8 weeks), progression-free survival, and overall survival. Exploratory analyses include investigation of biomarkers associated with treatment benefit. Results As of August 2019, 43 patients have been dosed across 6 dose cohorts (8mg - 800mg Q2W). The most common tumor types enrolled included: 10 NSCLC, 7 ovarian, 6 melanoma, 3 breast, and 3 CRC. NC318 has been well tolerated with no DLTs. The most common treatmentrelated AEs included diarrhea (4- grade 1 and 2-grade 2), pruritis (3- grade 1 and 1- grade 2), rashes (grade 1 and 2), arthralgias (2- grade 1), elevated amylase (grade 1, 2, and 3), and elevated lipase (grade 3 and 4). Tumor responses were evaluable in 32 patients; 11 patients have not reached their first assessment, and their efficacy data will be reported at the conference. Single agent activity has been seen in NSCLC including 1 CR (ongoing at 41 weeks), a PR (ongoing at 14 weeks), 1 stable disease with tumor reduction (ongoing for 26 weeks), and 2 with stable disease. NSCLC BORR: 2/7 or 29%, DCR: 5/7 or 71%. Conclusions NC318 has been well tolerated across multiple dose levels and has shown encouraging anti-tumor activity when administered as monotherapy. Single agent anti-tumor activity was observed in 5 of 7 NSCLC subjects refractory to PD-1 therapies

Background The evolving melanoma treatment algorithm has highlighted the role of immune checkpoint inhibitors in treating patients with this cancer. From the first drug approval in 2011 through today, many changes have occurred in treatment approaches. Selecting the most appropriate therapy with implementation of monitoring strategies for managing adverse events is vital. The goal of this study was to determine if participation in an educational activity can improve the proficiency of oncologists on the application of checkpoint inhibitors in adjuvant and metastatic melanoma. Methods An online continuing medical education (CME)-certified interactive, text-based activity developed by Medscape Education Oncology and the Society for Immunotherapy of Cancer included 2 patient cases, which served as the foundation for interactive questions. Educational design included a "test, then teach" approach to elicit cognitive dissonance, with evidence-based feedback provided following each learner response. A repeated pairs pre-/post-assessment study design with 3 case-based questions and 1 confidence question was used. A chi-square test assessed differences from pre-to post-assessment. P values .26 is extensive). The activity was launched online 2/25/19 and data were collected through 5/8/19. Results Participation in education resulted in statistically significant improvements and an extensive educational effect for oncologists (n=62; P < .001; V =.342). An average of 41% correctly responded to pre-assessment questions, increasing to 75% post-assessment. 40% of oncologists reported greater confidence prescribing immunotherapy in melanoma. Significant improvements in competency were observed in the following areas: * Selection of an evidence-based regimen for patients with melanoma in the adjuvant setting (24% vs 73%, P < 0.001, V = 0.484, Figure 1) * Identification of the most appropriate regimen for patients with metastatic melanoma following molecular testing (47% vs 74%, P <.01, V = 0.280, Figure 2) * Implementing team-based strategies for monitoring and managing irAEs (52% vs 77%, P <.01, V = 0.269, Figure 3) Conclusions This online interactive, case-based, CME-certified educational activity resulted in significant gains in oncologist competency in identifying and selecting appropriate treatments for patients with melanoma in the adjuvant and metastatic setting, and in implementing monitoring and management strategies (Figure 4). These results demonstrate the effectiveness of on-demand education in improving the translation of clinical knowledge into practice scenarios while improving clinician confidence. (Table Presented)

BACKGROUND:Recent evidence suggests that immunotherapy efficacy in melanoma is modulated by gut microbiota. Few studies have examined this phenomenon in humans, and none have incorporated metatranscriptomics, important for determining expression of metagenomic functions in the microbial community. METHODS:In melanoma patients undergoing immunotherapy, gut microbiome was characterized in pre-treatment stool using 16S rRNA gene and shotgun metagenome sequencing (n = 27). Transcriptional expression of metagenomic pathways was confirmed with metatranscriptome sequencing in a subset of 17. We examined associations of taxa and metagenomic pathways with progression-free survival (PFS) using 500 × 10-fold cross-validated elastic-net penalized Cox regression. RESULTS:Higher microbial community richness was associated with longer PFS in 16S and shotgun data (p < 0.05). Clustering based on overall microbiome composition divided patients into three groups with differing PFS; the low-risk group had 99% lower risk of progression than the high-risk group at any time during follow-up (p = 0.002). Among the species selected in regression, abundance of Bacteroides ovatus, Bacteroides dorei, Bacteroides massiliensis, Ruminococcus gnavus, and Blautia producta were related to shorter PFS, and Faecalibacterium prausnitzii, Coprococcus eutactus, Prevotella stercorea, Streptococcus sanguinis, Streptococcus anginosus, and Lachnospiraceae bacterium 3 1 46FAA to longer PFS. Metagenomic functions related to PFS that had correlated metatranscriptomic expression included risk-associated pathways of L-rhamnose degradation, guanosine nucleotide biosynthesis, and B vitamin biosynthesis. CONCLUSIONS:This work adds to the growing evidence that gut microbiota are related to immunotherapy outcomes, and identifies, for the first time, transcriptionally expressed metagenomic pathways related to PFS. Further research is warranted on microbial therapeutic targets to improve immunotherapy outcomes.

Despite major improvements in combatting metastatic melanoma since the advent of immunotherapy, the overall survival for patients with advanced disease remains low. Recently, there is a growing number of reports supporting an "obesity paradox," in which patients who are overweight or mildly obese may exhibit a survival benefit in patients who received immune checkpoint inhibitors. We studied the relationship between body mass index and progression-free survival and overall survival in a cohort of 423 metastatic melanoma patients receiving immunotherapy, enrolled and prospectively followed up in the NYU Interdisciplinary Melanoma Cooperative Group database. We analyzed this association stratified by first vs. second or greater-line of treatment and treatment type adjusting for age, gender, stage, lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, number of metastatic sites, and body mass index classification changes. In our cohort, the patients who were overweight or obese did not have different progression-free survival than patients with normal body mass index. Stratifying this cohort by first vs. non-first line immunotherapy revealed a moderate but insignificant association between being overweight or obese and better progression-free survival in patients who received first line. Conversely, an association with worse progression-free survival was observed in patients who received non-first line immune checkpoint inhibitors. Specifically, overweight and obese patients receiving combination immunotherapy had a statistically significant survival benefit, whereas patients receiving the other treatment types showed heterogeneous trends. We caution the scientific community to consider several important points prior to drawing conclusions that could potentially influence patient care, including preclinical data associating obesity with aggressive tumor biology, the lack of congruence amongst several investigations, and the limited reproduced comprehensiveness of these studies.

BACKGROUND:Since 2015, adjuvant therapy with ipilimumab is an approved treatment for stage III melanoma based on a significantly prolonged recurrence-free survival (RFS). At a median follow-up of 5.3 years, RFS, distant metastasis-free survival (DMFS) and overall survival (OS) were each significantly prolonged in the ipilimumab group compared with the placebo group, despite a 53.3% (ipilimumab) versus 4.6% (placebo) treatment discontinuation rate due to adverse events. We present now long-term follow-up results of this European Organisation for Research and Treatment of Cancer 18071 trial. PATIENTS, METHODS AND RESULTS/RESULTS:A total of 99 sites randomised 951 patients with stage III cutaneous melanoma (excluding lymph node metastasis ≤1 mm or in-transit metastasis) with adequate resection of lymph nodes to receive intravenous infusions of ipilimumab 10 mg/kg or placebo, every 3 weeks for 4 doses, then every 3 months for up to 3 years. The RFS, DMFS and OS, as reported by the local investigators, were assessed by the intention-to-treat analysis. Among 431 patients randomised at 63 sites and who were still alive at the analysis reported in 2016, recent follow-up information could be obtained for 264 patients. The median OS follow-up was 6.9 years. The RFS (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.63-0.88; P < 0.001), DMFS (HR: 95% CI: 0.76, 0.64-0.90; P = 0.002) and OS (HR: 0.73, 95% CI: 0.60-0.89; P = 0.002) benefit observed in the ipilimumab group was durable with an 8.7% absolute difference at 7 years for OS. The benefit was consistent across subgroups. CONCLUSIONS:Adjuvant therapy with ipilimumab prolongs RFS, DMFS and OS significantly. The benefit is sustained long term and consistent across subgroups.

We investigated the role of chemokines in regulating T cell accumulation in solid tumors. CCL5 and CXCL9 overexpression was associated with CD8⁺ T cell infiltration in solid tumors. T cell infiltration required tumor cell-derived CCL5 and was amplified by IFN-γ-inducible, myeloid cell-secreted CXCL9. CCL5 and CXCL9 coexpression revealed immunoreactive tumors with prolonged survival and response to checkpoint blockade. Loss of CCL5 expression in human tumors was associated with epigenetic silencing through DNA methylation. Reduction of CCL5 expression caused tumor-infiltrating lymphocyte (TIL) desertification, whereas forced CCL5 expression prevented Cxcl9 expression and TILs loss, and attenuated tumor growth in mice through IFN-γ. The cooperation between tumor-derived CCL5 and IFN-γ-inducible CXCR3 ligands secreted by myeloid cells is key for orchestrating T cell infiltration in immunoreactive and immunoresponsive tumors.