Date Published: May 26, 2017
Publisher: Public Library of Science
Author(s): Alexandra Snyder, Tavi Nathanson, Samuel A. Funt, Arun Ahuja, Jacqueline Buros Novik, Matthew D. Hellmann, Eliza Chang, Bulent Arman Aksoy, Hikmat Al-Ahmadie, Erik Yusko, Marissa Vignali, Sharon Benzeno, Mariel Boyd, Meredith Moran, Gopa Iyer, Harlan S. Robins, Elaine R. Mardis, Taha Merghoub, Jeff Hammerbacher, Jonathan E. Rosenberg, Dean F. Bajorin, John D. Minna
Abstract: BackgroundInhibition of programmed death-ligand 1 (PD-L1) with atezolizumab can induce durable clinical benefit (DCB) in patients with metastatic urothelial cancers, including complete remissions in patients with chemotherapy refractory disease. Although mutation load and PD-L1 immune cell (IC) staining have been associated with response, they lack sufficient sensitivity and specificity for clinical use. Thus, there is a need to evaluate the peripheral blood immune environment and to conduct detailed analyses of mutation load, predicted neoantigens, and immune cellular infiltration in tumors to enhance our understanding of the biologic underpinnings of response and resistance.Methods and findingsThe goals of this study were to (1) evaluate the association of mutation load and predicted neoantigen load with therapeutic benefit and (2) determine whether intratumoral and peripheral blood T cell receptor (TCR) clonality inform clinical outcomes in urothelial carcinoma treated with atezolizumab. We hypothesized that an elevated mutation load in combination with T cell clonal dominance among intratumoral lymphocytes prior to treatment or among peripheral T cells after treatment would be associated with effective tumor control upon treatment with anti-PD-L1 therapy. We performed whole exome sequencing (WES), RNA sequencing (RNA-seq), and T cell receptor sequencing (TCR-seq) of pretreatment tumor samples as well as TCR-seq of matched, serially collected peripheral blood, collected before and after treatment with atezolizumab. These parameters were assessed for correlation with DCB (defined as progression-free survival [PFS] >6 months), PFS, and overall survival (OS), both alone and in the context of clinical and intratumoral parameters known to be predictive of survival in this disease state.Patients with DCB displayed a higher proportion of tumor-infiltrating T lymphocytes (TIL) (n = 24, Mann-Whitney p = 0.047). Pretreatment peripheral blood TCR clonality below the median was associated with improved PFS (n = 29, log-rank p = 0.048) and OS (n = 29, log-rank p = 0.011). Patients with DCB also demonstrated more substantial expansion of tumor-associated TCR clones in the peripheral blood 3 weeks after starting treatment (n = 22, Mann-Whitney p = 0.022). The combination of high pretreatment peripheral blood TCR clonality with elevated PD-L1 IC staining in tumor tissue was strongly associated with poor clinical outcomes (n = 10, hazard ratio (HR) (mean) = 89.88, HR (median) = 23.41, 95% CI [2.43, 506.94], p(HR > 1) = 0.0014). Marked variations in mutation loads were seen with different somatic variant calling methodologies, which, in turn, impacted associations with clinical outcomes. Missense mutation load, predicted neoantigen load, and expressed neoantigen load did not demonstrate significant association with DCB (n = 25, Mann-Whitney p = 0.22, n = 25, Mann-Whitney p = 0.55, and n = 25, Mann-Whitney p = 0.29, respectively). Instead, we found evidence of time-varying effects of somatic mutation load on PFS in this cohort (n = 25, p = 0.044). A limitation of our study is its small sample size (n = 29), a subset of the patients treated on IMvigor 210 (NCT02108652). Given the number of exploratory analyses performed, we intend for these results to be hypothesis-generating.ConclusionsThese results demonstrate the complex nature of immune response to checkpoint blockade and the compelling need for greater interrogation and data integration of both host and tumor factors. Incorporating these variables in prospective studies will facilitate identification and treatment of resistant patients.
Partial Text: Atezolizumab has demonstrated responses in 15%–25% of patients with advanced urothelial carcinoma and improved survival compared to historical expectations [1,2]. Similar to predictive factor analyses in melanoma, colon cancer, and non-small cell lung cancer studies with other checkpoint blockade agents, Rosenberg and colleagues reported a statistically significant association between mutation load and response to atezolizumab in urothelial cancer patients . However, mutation load in the atezolizumab study was predicted based on an estimate using a targeted panel and not with whole exome sequencing (WES). Similar to findings from prior studies, the association between this predicted mutation load and outcomes in patients with urothelial cancer was not dichotomous; there were tumors from patients with elevated mutation load that did not respond to therapy, and vice versa. Additionally, positive programmed death-ligand 1 (PD-L1) staining of infiltrating immune cells by immunohistochemistry was associated with, but poorly predicted, response. A statistical model suggested that both PD-L1 staining and mutation load impacted the likelihood of response. However, the authors did not recommend their clinical use.
The treatment of previously incurable metastatic solid tumors with checkpoint blockade agents has led to dramatic success in a minority of patients, a finding that has generated substantial excitement in the field, with associated correlative studies and drug development. Here, we undertook the in-depth characterization of tumors and peripheral blood from 29 patients treated on IMvigor 210, a Phase II study in which 310 patients were treated with the anti-PD-L1 agent atezolizumab. In this cohort of patients, we illustrate the importance of host immune factors, including intratumoral and peripheral TCR clonality, infiltration, and expansion, to clinical outcomes. We did not find a significant association between mutation or expressed neoantigen load and PFS or DCB (defined as PFS > 6 months). However, we did observe a time-dependent relationship between mutation load and outcome, wherein a relationship between mutation burden and outcome could only be detected in those patients surviving greater than 3 months. This analysis implies that patients who experienced rapid progression may display systemic indicators of immune deficiency despite elevated mutation load in the tumors. Calculation of the hazard ratios for each measured biomarker and clinical factor underscores the concept that a complex interaction of both host and tumor variables determines whether a patient will experience clinical benefit from anti-PD-L1 therapy. Although the overall study found significant associations between mutation load as measured by the Foundation Medicine targeted sequencing panel and radiographic response , there was no statistically significant association between mutation load and DCB or survival in the patient subset studied here, despite the similarity of our study population to the parent study. This contrast may be due to a combination of factors. First, though statistically significant, the association in the overall study was not categorical: as in other studies of mutation load, this factor alone was not predictive of response. Second, we have less power to detect this association in our smaller subset compared with the larger studied cohort. Third, standardized definitions and calculations of mutation load do not exist as of yet; each published study has used differing methodologies [2,10,22,23]. Indeed, in this study, depending on the method used, the association between mutation load and clinical outcomes varied from p < 0.08 to p > 0.4 (area under the curve [AUC] values and p-values in S1 Table). To illustrate the fickle nature of defining mutation load, counting only the mutations excluded by BQSR, as opposed to only those remaining after BQSR, showed a significant association with DCB. Together, these findings underscore the need for improved and standardized mutation calling methods. The weak association of mutation load with DCB and the lack of such standardization render this biomarker unfit for application to individual patients at present. Furthermore, if validated in another dataset, this analysis implies that a clinical and immunological state may exist in patients with advanced cancer, such that patients with very rapidly progressing disease and expected death in less than 3 months do not respond despite the presence of positive intratumoral biomarkers.