Emerging Tissue and Serum Markers for Immune Checkpoint Inhibitors Kyong Hwa Park MD, PhD Medical Oncology Korea University College of Medicine
Contents Immune checkpoint inhibitors in clinical practice Biomarkers for immune checkpoint inhibitors - Tissue or blood based multi-level assays Immunotherapy in breast cancer: recent signatures Emerging biomarkers
Atezolizumab (Genentech/Roche)
Current Approval Status of ITA by USFDA
Immunologic Armaments in Oncology Clinic Anti-CTLA4 Anti-CD137 agonist Anti-OX40 agonist Anti-CD27 agonist IL-2 IL-12 Anti-VEGF Vaccine IFN-alpha GM-CSF Anti-CD40 agonist TLR agonist CARs Chemotherapy Radiation therapy Targeted therapy Anti-PD1 Anti-PD-L1 IDO inhibitors Nat Rev Genetics Aug 2016
Combination immunotherapy : More trials, Better targeted 2017 Nature
PD-1/PD-L1 Blockades in MBC
Response rate: 18.5% No response in LDH > 2X UNL Pembrolizumab in TNBC :Phase Ib KEYNOTE-012 Study J Clin Oncol. 2016 May 2
Avelumab in Metastatic Breast Cancer All MBC Patients (N=111) ORR: 3% TNBC Patients (N=46) ORR: 5% PD-L1+ PD-L1-
Hyperprogressors! Clin Cancer Res; 2017
Clinical Questions that you might have. Metastatic Cancer Remission Immune Targeted Agents Patient selection? Still immune response? Retreat? Anti-tumor immune response? How long treat? Combination approach? Toxicities?
KEYNOTE-001: Phase Ib study of Pembrolizumab for the Treatment of NSCLC PD-L1 expression status by IHC: anti PD-L1 antibody clone 22C3 (Merck) Cells counted: neoplastic and intercalated mononuclear inflammatory cells N Engl J Med 2015;372:2018-28.
Mechanisms of PD-1 Expression Nature Immunology 14, 1212 1218 (2013)
PD-1/PD-L1: Exhaustion of T cells 1) Antagonizing TCR signaling 2) Decreased survival, proliferation, altered metabolism 3) Reduced proliferation via RAS path 4) Altered transcription 5) Altered T cell motility Trends in Immunology April 2015, Vol. 36, No. 4
Technical Complexity With PD-L1: Different Thresholds for Expression There are no harmonized criteria to define PD-L1 positivity by IHC 1 Various PD-L1 IHC assays differ in terms of the cells assessed, scoring methods, and thresholds used: Cells assessed Nivolumab Dako Assay 2 Tumour cells Pembrolizumab Dako Assay 3,4 Tumour cells and immune cells Atezolizumab Ventana Assay 5,6 Tumour cells and immune cells Durvalumab Ventana Assay 7 Tumour cells Ab clone 28-8 22C3 SP142 SP263 Scoring method Tumour score: P ercentage of cell s with membran e staining at any intensity Proportion score: Percentage of cells with membrane st aining at any inten sity Tumour cell (TC) score: staining percentage of tumour cells Immune cell (IC) score: staining percentage of tumour ar ea Percentage tumour c ells with membrane staining PD-L1 Expression Levels <1% or 1%, <5% or 5%, <10% or 10% 50% TC3 or IC3: TC 50% or IC 10% TC2/3 or IC2/3: TC or IC 5% TC1/2/3 or IC1/2/3: TC or IC 1% TC0 and IC0: TC and IC <1% 25% Ab, antibody; IHC, immunohistochemistry; PD-L1, programmed death ligand-1. 1. Heskamp S et al. Cancer Res. 2015. [Epub ahead of print]. 2. Phillips T et al. Appl Immunohistochem Mol Morphol. 2015. doi:10.1097/pai.0000000000000256. 3. Dolled-Filhart M et al. Poster presentation at ASCO 2015. 11065. 4. Rizvi N et al. Poster presentation at ASCO 2015. 8026. 5. Spira AI et al. Oral presentation at ASCO 2015. 8010. 7. Spigel DR et al. Poster presentation at ASCO 2015. 8028. 7. Rebelatto MC et al. Poster presentation at ASCO 2015. 8033.
PD-L1 as a Biomarker?: Issues Tumor heterogeneity Interval between biopsy and treatment Primary vs metastatic disease Ab and staining conditions Defining a positive result (cut-offs) - Immune cells vs tumor cells - Location of expression: intracellular vs surface vs stroma - Intensity, percent of positive cells - Distribution
HER-2 type Breast Cancer: PANACEA 2017 SABCS Loi et al
Genomic Signatures of TIL is Prognostic in HER2 Type Luminal low Luminal high HER-2 TNBC 2018 BCRT, doi: 10.1007/s10549-017-4502-3
Clinical Development in Cancers with High mutational burden Science 3 April 2015
Mutational Load Mutational Landscape of Melanoma according to the CTLA-4 blockade Response Survival in Discovery set Snyder A et al. N Engl J Med 2014;371:2189-2199.
Mutation burden, clinical response, and factors contributing to mutation burden: NSCLC Science 3 April 2015
Neoantigen burden & Intratumoral Heterogeneity (ITH) Science MAR 2016
Clonal Heterogeneity and Immune Signature in TNBC N=193 TNBC with follow up data @ TCGA JAMA Oncol. 2017;3(12):1707-1711. doi:10.1001/jamaoncol.2017.2140
TIL Infiltration and Response to anti PD-1: Melanoma J Clin Invest. 2016;126(9):3447-3452. doi:10.1172/jci87324.
Tumoral CD8+ T cell Infiltration after Pembrolizumab Response (n=22) Proliferating T cells Progression (n=24) Nature 515, 568 571 (27 November 2014)
Change in TCR Repertoire Theoretical repertoire of 10 15 10 20 different TCRs that could be generated in humans Effective anti-tumor immunity increased TCR clonality Genes and Immunity (2016) Nature (2014)
T cell Diversity and Mutational Burden Science 3 April 2015 Nat Genetics 2016
What we should know for Rational application of Immune Targeted Agents (ITA) Immune responses with standard anti-cancer treatment Indicators to judge Immune-related Response - Pseudo-progression - Delayed but prolonged response, delayed K-M curve separation - Mixed responses Predictors for Immune-related Adverse Events Timing for Re-treatment: monitoring immunosuppressive TME
Best Information is in Tissue
Multiplex IHC NanoString Analysis : KEYNOTE-001 Peter Lee, 2016 SABCS
Assessment of Tumor Immune Microenvironment Static markers Dynamic markers Genomic analysis (WES, targeted seq) IHC for molecular & immune markers Flow/CyTOF for phenotyping RNA seq for profiling the transcriptome Single cell (TCR seq, RNAseq) Analysis of germline SNPs Flow/CyTOF for phenotyping (best if paired with tumor) Cytokine profiling in serum Exosome analysis (WES, RNAseq, paired with tumor) Single cell (TCRseq, RNAs eq)
Blood mirrors anti-tumor immune responses! - Immune cell profiles - Cytokines - PBMC Immunomics
F/81, Metastatic Breast Cancer (TNBC) Baseline Treatment week #18 Treatment week #16
Cell-based Analysis Flow-cytometry (FACS) Easy accessibility High-throughput High signal overlap ~16 parameters Mass Cytometry (Cy-TOF) No signal overlap >40 parameters High cost Low-throughput Limited availability
MDSC in Ipilimumab Treated Melanoma Patients MDSC with Treatment MDSC vs Response MDSC vs LDH MDSC vs M stage Cancer Immunol Immunother (2014) 63:247 257
Change in circulating Lymphocytes after Ipilimumab Early change in ALC Delayed change in CD8 Delayed change in EØ Delayed change in CD4 *Early: 2-8 weeks after Tx, Delayed: 8-18 weeks after Tx. 2016 CCR
Anti-PD1 Response : T cell invigoration & Tumor burden 2017 Nature doi:10.1038/nature22079
Anti-PD1 Response : T cell invigoration/tumor burden ratio Tumor burden (pre) Penn PD-1+CD8 (pre) MSKCC 2017 Nature doi:10.1038/nature22079
Gut microbiome influences efficacy of PD-1 based immunotherapy All cancer Frequency of Akkermansia NSCLC Science 05 Jan 2018: DOI: 10.1126/science.aan3706
Dynamic immune monitoring is necessary in Development of new IO-based cancer treatment. : Best combination between ITA-ITA, SOC-ITA. Endpoint measures Decision for treatment, retreatment Public issue Neoantigen discovery & precision medicine Need collaborative effort in academic society!
Bio-specimens reflecting Anti-tumor Immune Responses Translational research for optimal immune monitoring Validation of immunoassays using clinical samples Establish the most feasible, standardized assays for immune monitoring Annu. Rev. Med. 2014.65:185-202
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