Marc S. Ernstoff

Randomized Phase III Trial of High-Dose Interleukin-2 Versus Subcutaneous Interleukin-2 and Interferon in Patients With Metastatic Renal Cell Carcinoma

PURPOSE The Cytokine Working Group conducted a randomized phase III trial to determine the value of outpatient interleukin-2 (IL-2) and interferon alfa-2b (IFN) relative to high-dose (HD) IL-2 in patients with metastatic renal cell carcinoma. PATIENTS AND METHODS Patients were stratified for bone and liver metastases, primary tumor in place, and Eastern Cooperative Oncology Group performance status 0 or 1 and then randomly assigned to receive either IL-2 (5 MIU/m(2) subcutaneously every 8 hours for three doses on day 1, then daily 5 days/wk for 4 weeks) and IFN (5 MIU/m(2) subcutaneously three times per week for 4 weeks) every 6 weeks or HD IL-2 (600,000 U/kg/dose intravenously every 8 hours on days 1 through 5 and 15 to 19 [maximum 28 doses]) every 12 weeks. RESULTS One hundred ninety-two patients were enrolled between April 1997 and July 2000. Toxicities were as anticipated for these regimens. The response rate was 23.2% (22 of 95 patients) for HD IL-2 versus 9.9% (nine of 91 patients) for IL-2/IFN (P = .018). Ten patients receiving HD IL-2 were progression-free at 3 years versus three patients receiving IL-2 and IFN (P = .082). The median response durations were 24 and 15 [corrected] months (P = .18) [corrected] and median survivals were 17.5 and 13 months (P = .24). For patients with bone or liver metastases (P = .001) or a primary tumor in place (P = .040), survival was superior with HD IL-2. CONCLUSION This randomized phase III trial provides additional evidence that HD IL-2 should remain the preferred therapy for selected patients with metastatic renal cell carcinoma.

Three Phase II Cytokine Working Group Trials of gp100 (210M) Peptide Plus High-Dose Interleukin-2 in Patients With HLA-A2–Positive Advanced Melanoma

PURPOSE High-dose interleukin-2 (IL-2) induces responses in 15% to 20% of patients with advanced melanoma; 5% to 8% are durable complete responses (CRs). The HLA-A2-restricted, modified gp100 peptide (210M) induces T-cell immunity in vivo and has little antitumor activity but, combined with high-dose IL-2, reportedly has a 42% (13 of 31 patients) response rate (RR). We evaluated 210M with one of three different IL-2 schedules to determine whether a basis exists for a phase III trial. PATIENTS AND METHODS In three separate phase II trials, patients with melanoma received 210M subcutaneously during weeks 1, 4, 7, and 10 and standard high-dose IL-2 during weeks 1 and 3 (trial 1), weeks 7 and 9 (trial 2), or weeks 1, 4, 7, and 10 (trial 3). Immune assays were performed on peripheral-blood mononuclear cells collected before and after treatment. RESULTS From 1998 to 2003, 131 patients with HLA-A2-positive were enrolled. With 60-month median follow-up time, the overall RR for 121 assessable patients was 16.5% (95% CI, 10% to 26%); the RRs were 23.8% in trial 1 (42 patients), 12.5% in trial 2 (40 patients), and 12.8% in trial 3 (39 patients). There were 11 CRs (9%) and nine partial responses (7%), with 11 patients (9%) progression free at >or= 30 months. Immune studies including assays of CD3-zeta expression and numbers of CD4(+)/CD25(+)/FoxP3(+) regulatory T cells, CD15(+)/CD11b(+)/CD14(-) immature myeloid-derived cells, and CD8(+)gp100 tetramer-positive cells in the blood did not correlate with clinical benefit. CONCLUSION The results again demonstrate efficacy of high-dose IL-2 in advanced melanoma but did not demonstrate the promising clinical activity reported with vaccine and high-dose IL-2 in any of three phase II trials.

Managing toxicities associated with immune checkpoint inhibitors: consensus recommendations from the Society for Immunotherapy of Cancer (SITC) Toxicity Management Working Group

Cancer immunotherapy has transformed the treatment of cancer. However, increasing use of immune-based therapies, including the widely used class of agents known as immune checkpoint inhibitors, has exposed a discrete group of immune-related adverse events (irAEs). Many of these are driven by the same immunologic mechanisms responsible for the drugs’ therapeutic effects, namely blockade of inhibitory mechanisms that suppress the immune system and protect body tissues from an unconstrained acute or chronic immune response. Skin, gut, endocrine, lung and musculoskeletal irAEs are relatively common, whereas cardiovascular, hematologic, renal, neurologic and ophthalmologic irAEs occur much less frequently. The majority of irAEs are mild to moderate in severity; however, serious and occasionally life-threatening irAEs are reported in the literature, and treatment-related deaths occur in up to 2% of patients, varying by ICI. Immunotherapy-related irAEs typically have a delayed onset and prolonged duration compared to adverse events from chemotherapy, and effective management depends on early recognition and prompt intervention with immune suppression and/or immunomodulatory strategies. There is an urgent need for multidisciplinary guidance reflecting broad-based perspectives on how to recognize, report and manage organ-specific toxicities until evidence-based data are available to inform clinical decision-making. The Society for Immunotherapy of Cancer (SITC) established a multidisciplinary Toxicity Management Working Group, which met for a full-day workshop to develop recommendations to standardize management of irAEs. Here we present their consensus recommendations on managing toxicities associated with immune checkpoint inhibitor therapy.

Analytical Validation of a Next-Generation Sequencing Assay to Monitor Immune Responses in Solid Tumors

We have developed a next-generation sequencing assay to quantify biomarkers of the host immune response in formalin-fixed, paraffin-embedded (FFPE) tumor specimens. This assay aims to provide clinicians with a comprehensive characterization of the immunologic tumor microenvironment as a guide for therapeutic decisions on patients with solid tumors. The assay relies on RNA-sequencing (seq) to semiquantitatively measure the levels of 43 transcripts related to anticancer immune responses and 11 transcripts that reflect the relative abundance of tumor-infiltrating lymphocytes, as well as on DNA-seq to estimate mutational burden. The assay has a clinically relevant 5-day turnaround time and can be conducted on as little as 2.5 ng of RNA and 1.8 ng of genomic DNA extracted from three to five standard FFPE sections. The standardized next-generation sequencing workflow produced sequencing reads adequate for clinical testing of matched RNA and DNA from several samples in a single run. Assay performance for gene-specific sensitivity, linearity, dynamic range, and detection threshold was estimated across a wide range of actual and artificial FFPE samples selected or generated to address preanalytical variability linked to specimen features (eg, tumor-infiltrating lymphocyte abundance, percentage of necrosis), and analytical variability linked to assay features (eg, batch size, run, day, operator). Analytical precision studies demonstrated that the assay is highly reproducible and accurate compared with established orthogonal approaches.

An update on the Society for Immunotherapy of Cancer consensus statement on tumor immunotherapy for the treatment of cutaneous melanoma: version 2.0

BackgroundCancer immunotherapy has been firmly established as a standard of care for patients with advanced and metastatic melanoma. Therapeutic outcomes in clinical trials have resulted in the approval of 11 new drugs and/or combination regimens for patients with melanoma. However, prospective data to support evidence-based clinical decisions with respect to the optimal schedule and sequencing of immunotherapy and targeted agents, how best to manage emerging toxicities and when to stop treatment are not yet available.MethodsTo address this knowledge gap, the Society for Immunotherapy of Cancer (SITC) Melanoma Task Force developed a process for consensus recommendations for physicians treating patients with melanoma integrating evidence-based data, where available, with best expert consensus opinion. The initial consensus statement was published in 2013, and version 2.0 of this report is an update based on a recent meeting of the Task Force and extensive subsequent discussions on new agents, contemporary peer-reviewed literature and emerging clinical data. The Academy of Medicine (formerly Institute of Medicine) clinical practice guidelines were used as a basis for consensus development with an updated literature search for important studies published between 1992 and 2017 and supplemented, as appropriate, by recommendations from Task Force participants. ResultsThe Task Force considered patients with stage II-IV melanoma and here provide consensus recommendations for how they would incorporate the many immunotherapy options into clinical pathways for patients with cutaneous melanoma.ConclusionThese clinical guidleines provide physicians and healthcare providers with consensus recommendations for managing melanoma patients electing treatment with tumor immunotherapy.

Myeloid-derived suppressors cells (MDSC) correlate with clinicopathologic factors and pathologic complete response (pCR) in patients with urothelial carcinoma (UC) undergoing cystectomy

BACKGROUND Myeloid derived suppressor cells (MDSC) are heterogeneous immunosuppressive cells with potential predictive and prognostic roles in cancer. The association between MDSC, clinicopathologic factors, and pathologic response in patients with bladder urothelial carcinoma (UC) was explored. METHODS Peripheral blood or tissue were collected from patients with UC undergoing definitive surgery. MDSCs levels were measured in peripheral blood mononuclear cells and fresh tumor tissue. MDSCs were identified by flow cytometry and defined as total MDSC (T-MDSC) CD33+/HLADR-. From this population, 3 subsets were identified: polymorphonuclear-MDSC (PMN-MDSC) defined as CD33+/HLADR-/CD15+/CD14-, monocytic-MDSC (M-MDSC) defined as CD33+/HLADR-/CD15-/CD14+, and immature-MDSC (I-MDSC) defined as CD33+/HLADR-/CD15-/CD14-. MDSC populations were presented as % of live nucleated blood cells. Spearman correlations (r) and Wilcoxon rank sum test were used to assess correlations between MDSC populations, clinicopathologic factors, and pathologic complete response (pCR). RESULTS 85 patients scheduled to undergo cystectomy from February 2015 through Dec 2016 were included. All patients had blood drawn for analysis and 23 patients had residual tumor tissue collected for analysis at the time of surgery. Of these 85, 74 (87%) were men with a median age at diagnosis of 68 (range: 44-87). Pure UC was the most common histology (75%); 28 (35%) patients had prior treatment with intravesical therapy and 36 (42%) were treated with neoadjuvant chemotherapy, primarily gemcitabine plus cisplatin (n = 24). On surgical pathology, 18 (21%) of the patients had pCR, 11 (13%) had positive lymph nodes, and 20 patients (24%) had lymphovascular invasion. Statistically significant associations were found between circulating MDSC levels and pCR rates (P<0.01), absolute neutrophil-lymphocyte ratio (P = 0.008), and histology (P = 0.01). Tumor % M-MDSCs were negatively associated with lymphovascular invasion (P = 0.04). There were no significant correlations between peripheral blood mononuclear cells and tumor MDSC subtypes. CONCLUSIONS Blood and tissue MDSC levels correlate with several clinicopathologic factors and may predict for pCR. Future studies are needed to highlight the role of MDSC in predicting long-term outcomes and to determine the clinical implications of these findings.

Emerging role of RNA binding protein UNR/CSDE1 in melanoma

The prognosis of metastatic melanoma remains poor despite recent advances in targeted and immunotherapy. Deciphering the mechanisms of tumor invasion and metastasis, and elucidating new targets for drug development could substantially improve survival in patients with metastatic melanoma. In this regard, RNA binding proteins (RBP) play an important role in RNA metabolism and are drawing considerable attention as drivers of oncogenesis and therapeutic targets. RNA binding proteins synchronize with the target RNA to play a key role in the regulation of cellular processing and are important for gene transcription and post-translational regulation (1). Wurth et al . recently published an article in Cancer Cell exploring the role of Upstream-of-N-Ras (UNR) in invasion and progression of melanoma cells (2). The UNR gene was identified as a transcription unit located immediately upstream of N-Ras in the genome of several mammalian species (3). UNR protein consists of five cold-shock domains (CSDs). These domains bind single stranded DNA and RNA and consist of ~70 amino-acid residues (4). CSD containing proteins are involved in transcriptional and post-transcriptional control of gene expression. Experiments in Drosophila species have shown the role of UNR in regulating translation of oncogenic transcripts (5).

Abstract 620: Tumor microenvironment heterogeneity is not identified across multiple histologically similar tumors from the same patient

Introduction: Tumor heterogeneity has been well documented for mutational analysis in virtually all types of tumors and is accepted as a true finding. Heterogeneity of the tumor microenvironment (TME) in the context of response to checkpoint inhibitors has not been well studied; the belief is that variation will be identified across multiple tumors from the same patient. The expectation is that multiple tumors from a single patient would demonstrate extensive TME heterogeneity driven by the neoplasm. Methods: We validated and utilized a targeted RNA-seq immune panel of >350 genes to interrogate the TME of 49 different tumors from 17 unique patients. These samples for one patient represented primary and metastatic tumors that were separated by multiple years. Prior to this study we built a reference database of RNA-seq immune results for this panel of 167 samples. An in-depth analysis of genes associated with checkpoint inhibition (CPI) and tumor infiltrating lymphocytes (TILs) were the focus of the comparative analysis. Unsupervised analysis and gene rank by RNA-seq were the primary modes of comparison. Results: For more than one-half of these patients the different tumors for a single patient separated by multiple years more closely resembled the other tumors from that patient than the reference population by unsupervised clustering. When ranked by LOW, MODERATE, or HIGH expression of genes associated with TILs or CPI the results for the majority of patients were highly concordant: LOW TILs / LOW CPI associated gene expression. Conclusion: Our results support a paradigm shift in the influence of the host on TME heterogeneity with evidence that the host and not the neoplastic cells are the primary determining factor. TME heterogeneity is not identified across multiple tumors of the same histology collected from different sites across time points from the same patient. This study does not evaluate multiple primary tumors from the same patient, but is an additional study we have planned. Citation Format: Carl D. Morrison, Jeffrey Conroy, Sean Glenn, Blake Burgher, Sarabjot Pabla, Maochun Qin, Antonios Papanicolau-Sengos, Jon Andreas, Vincent Giamo, Mary Nesline, Shipra Gandhi, Manu Pandey, Nischala Ammannagari, Kunle Odunsi, Marc Ernstoff, Mark Gardner. Tumor microenvironment heterogeneity is not identified across multiple histologically similar tumors from the same patient [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 620. doi:10.1158/1538-7445.AM2017-620

Abstract 3827: NCI 8628 - A randomized phase II study of Ziv-aflibercept (Z) and high dose Interleukin-2 (IL-2) or IL-2 alone for inoperable stage III or IV melanoma

Background: IL-2 plays a central role in antitumor immunity. VEGF plays a critical role in angiogenesis and host innate and adaptive immunity. High baseline serum VEGF was associated with non-response to IL-2. Z, a high-affinity soluble decoy VEGF receptor, may deplete VEGF prior to IL-2 to reverse the immunosuppressive impact of VEGF and enhance antitumor T cell response. Methods: NCI8628 was a phase II trial of Z and IL-2 (A) versus IL-2 alone (B) randomized 2:1. Eligible patients (pts): Stage III inoperable or Stage IV melanoma. Up to two prior regimens for metastatic melanoma and stable treated brain metastases were allowed. The primary endpoint was progression-free survival (PFS). Results: A total of 89 pts were enrolled, but 5 who never started study treatment were excluded. Six pts (4 in A and 2 in B) who were treated but withdrew early without a response assessment were considered non-responders in this analysis. Pt and disease characteristics are summarized in Table 1. Median number of IL2 cycles was 3 (A) and 2 (B) and of Z cycles in A was 3 (1 - 31). Median follow up for all alive patients was 19 months. Among 84 treated pts (55 in A and 29 in B), there was significant improvement in PFS in favor of A: median and 95% CI of 6.9 (4.2 - 8.8) months vs 2.1 (1.7 - 4.1), logrank p Conclusions: The combination of Z and IL2 significantly improved PFS over IL2 alone, meeting the study’s primary endpoint. The regimen was relatively safe and manageable. Correlative and mechanistic studies are ongoing. Citation Format: Ahmad A. Tarhini, Paul H. Frankel, Christopher Ruel, Marc S. Ernstoff, Timothy M. Kuzel, Theodore F. Logan, Nikhil I. Khushalani, Hussein A. Tawbi, Kim A. Margolin, Sanjay Awasthi, David F. McDermott, Alice Chen, Primo N. Lara, John M. Kirkwood. NCI 8628 - A randomized phase II study of Ziv-aflibercept (Z) and high dose Interleukin-2 (IL-2) or IL-2 alone for inoperable stage III or IV melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3827. doi:10.1158/1538-7445.AM2017-3827

Induction of T cell precursors in advanced melanoma treated with autologous tumor lysate loaded dendritic cells

2623 Background: Immunotherapy in melanoma patients (pts) is limited by tumor-induced effector cell inhibition. Dendritic cells (DC) are powerful initiators of tumor-specific immune responses. We proposed a pilot study that hypothesized that DC matured ex vivofrom the peripheral blood (PB) and pulsed with autologous tumor lysate (TuLy) would stimulate tumor-specific immune activation. METHODS 6 stage III/IV melanoma pts were enrolled and CD14+ precursors were obtained from PB by apheresis and elutriation prior to each treatment. DC were cultured ex vivo for 9 days with IL-4 and GM-CSF, pulsed with autologous TuLy and matured with TNFa. Pts received 3 treatments administered intravenously (IV) over 5-10 minutes at 4 week intervals. Efficiency of DC generation was determined by measuring total DC per apheresis and phenotype. NCI Common Toxicity Criteria v2.0 was used. Tumor-specific immune induction was evaluated using the Dye Dilution Proliferation Assay which measures T cell precursor frequencies (Tp) in response to stimuli; in this case pulsed or unpulsed mature DC. RESULTS 3 pts each have been treated with 1x106and 5x106DC respectively. Adequate yields of DC were achieved for all treatments. Toxicity was minimal with transient grade 2 ataxia. Mature DC highly expressed MHC class I and II, costimulatory markers (CD80, CD86, CD40) and the maturity marker CD83. We observed a 6-fold increase in CD8+ Tp and 1.5-fold increase in CD4+ Tp after 2 treatments (n=2) as shown in the table. Elevated Tp persisted 30 days following completion of treatment. CONCLUSIONS Ex vivogeneration and IV administration of mature DC is feasible and safe. Preliminary data support induction of tumor-specific T cells evidenced by increased Tp. [Figure: see text] No significant financial relationships to disclose.