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Lynette M Sholl



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    IBS18 - Essentials in Biomarker Testing for Lung Cancer (Ticketed Session) (ID 49)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Pathology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 07:00 - 08:00, Tokyo (1982)
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      IBS18.02 - Tests by Next Generation Sequencing (Now Available) (ID 3370)

      07:00 - 08:00  |  Presenting Author(s): Lynette M Sholl

      • Abstract
      • Presentation
      • Slides

      Abstract

      Next generation sequencing (NGS) encompasses a family of technologies that effectively multiplex and digitize nucleic acid sequencing. The major technical platforms used in clinical practice include hybrid capture and amplicon sequencing, either of which can be applied to tumor or cell free DNA testing. Essential steps for any NGS assay include: 1) capture of some or all of the genome; 2) massively parallel sequencing; 3) alignment of the sequencing reads to a reference genome; 4) variant calling and 5) variant interpretation. Each of these steps has a major influence on the assay output, including breadth of coverage (how much of the genome to sequence?), depth of sequencing (how sensitive is the assay?), accuracy, and clinical relevance. In general, DNA hybrid capture assays are optimized for breadth, both in terms of overall genomic real estate (from 100s of genes to the entire genome) and for capturing complex changes such as copy alterations and structural variants. The drawback to the approach, however, is high cost, limited analytic sensitivity, and suboptimal capture and sequencing of highly repetitive regions, leading to poorly-covered or uncovered areas of the genome. Amplicon based sequencing, in contrast, requires a much more focused design. This approach uses PCR to capture the genomic regions of interest and then employs massively parallel sequencing to interrogate each individual PCR amplicon. This approach is lower cost, more sensitive, and faster than hybrid capture, but is best suited for small targeted panels (10s to 100s of genes), is less reliable for detection of copy number changes and rearrangements, and is prone to PCR-related errors. Many of the large academic and commercial NGS panels rely on hybrid capture technology to detect a range of mutations, losses and amplifications, and insertion-deletion/rearrangement events occurring across several hundred genes implicated in human tumorigenesis.1,2

      In addition to revealing the mutational status of characterized oncogenes and tumor suppressor genes, these panels can uncover a host of changes to the DNA representing underlying mutagenic processes or DNA repair defects. For example, mismatch repair deficiency/microsatellite instability is characterized by insertion-deletion events in association with repetitive stretches of DNA and/or certain patterns of nucleotide substitution (C>T changes with an adjacent 3' or 5' guanine). Many laboratories have leveraged existing panel sequencing assays to detect mismatch repair deficiency and are beginning to replace PCR and/or immunohistochemistry screening to identify patients at risk of Lynch syndrome and/or as a biomarker for response to PD-1 inhibition.1,3 Beyond detection of specific DNA damage signatures, the ability to quantify mutational changes on NGS platforms has given rise to the concept of tumor mutational burden (TMB) and the recognition that this may serve as a biomarker for response to immune checkpoint inhibitors. Attempts to compare TMB values across testing platforms has focused attention on the wide technical and informatic variation intrinsic to different NGS assays that may influence TMB calculation, including gene content, choice of tumor-only vs tumor/normal paired sequencing, germline filtration methods, and unrelated clonal processes (such as clonal hematopoeisis). 4 As a result, identification of a single cutpoint for predicting therapeutic response to immunotherapy is challenging and has driven efforts to standardize NGS panels for TMB detection. 5

      While most DNA-based NGS panels in use today are sufficiently sensitive for reliable detection of single nucleotide substitutions (e.g. KRAS G12D; EGFR L858R) or small insertion deletions (EGFR exon 19 deletion mutations), these panels often fall short in detection of large structural variants including rearrangements.6 Functional rearrangements typically result from gene breakages and fusions occurring within intronic (non-coding) sequences. On a per gene basis, introns tend to be significantly larger than coding exons, which means that an NGS assay designed with cost and sensitivity concerns in mind must have restricted overall intronic coverage. In addition, introns tend to contain a much higher proportion of repetitive elements, thus the tools used for rearrangement detection must be able to discern the presence of these variants despite low sequencing coverage and nonspecific sequence mismatches. In practice, these issues lead to reduced clinical sensitivity for detection of large deletions and rearrangement events. RNA-based NGS platforms, including targeted RNAseq and anchored multiplex PCR, detect the fusion transcript directly, eliminating the need to target introns. Labs may now employ workflows in which a DNA assay is used for mutation and copy changes and an RNA assay is used for rearrangement detection. A substantial minority of DNA sequencing-negative lung cancers may have a fusion detected by an RNA assay, leading some groups to advocate for sequential DNA then RNA testing protocols in driver negative lung adenocarcinomas.7

      NGS is a powerful tool to guide the diagnosis and treatment of patients with lung cancer. Improvements in assay design, chemistry, bioinformatics and variant interpretation will continue to increase its reliability and use across tumor and specimen types. Coordination with experts versed in the limitations of the technology is essential for appropriate implementation in clinical practice.

      References:

      1. Zehir A, Benayed R, Shah RH, et al. Mutational landscape of metastatic cancer revealed from prospective clinical sequencing of 10,000 patients. Nat Med 2017; 23(6): 703-13.

      2. Sholl LM, Do K, Shivdasani P, et al. Institutional implementation of clinical tumor profiling on an unselected cancer population. JCI Insight 2016; 1(19): e87062.

      3. Papke DJ, Jr., Nowak JA, Yurgelun MB, et al. Validation of a targeted next-generation sequencing approach to detect mismatch repair deficiency in colorectal adenocarcinoma. Mod Pathol 2018; 31(12): 1882-90.

      4. Garofalo A, Sholl L, Reardon B, et al. The impact of tumor profiling approaches and genomic data strategies for cancer precision medicine. Genome Med 2016; 8(1): 79.

      5. Miao D, Margolis CA, Vokes NI, et al. Genomic correlates of response to immune checkpoint blockade in microsatellite-stable solid tumors. Nat Genet 2018; 50(9): 1271-81.

      6. Davies KD, Le AT, Sheren J, et al. Comparison of Molecular Testing Modalities for Detection of ROS1 Rearrangements in a Cohort of Positive Patient Samples. J Thorac Oncol 2018; 13(10): 1474-82.

      7. Benayed R, Offin M, Mullaney K, et al. High Yield of RNA Sequencing for Targetable Kinase Fusions in Lung Adenocarcinomas with No Mitogenic Driver Alteration Detected by DNA Sequencing and Low Tumor Mutation Burden. Clin Cancer Res 2019.

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    MA09 - EGFR & MET (ID 128)

    • Event: WCLC 2019
    • Type: Mini Oral Session
    • Track: Targeted Therapy
    • Presentations: 2
    • Now Available
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      MA09.05 - Genomic Correlates of Differential Response to EGFR-Directed Tyrosine Kinase Inhibitors (Now Available) (ID 1169)

      15:15 - 16:45  |  Author(s): Lynette M Sholl

      • Abstract
      • Presentation
      • Slides

      Background

      Oncogenic mutations in EGFR are powerful biomarkers of response to EGFR tyrosine kinase inhibitors (TKIs) in non-small cell lung cancer (NSCLC). However, there remains significant heterogeneity in duration of response to therapy and overall survival, and the molecular determinants of this differential response have been incompletely characterized.

      Method

      We identified NSCLC patients at our institution with sensitizing oncogenic EGFR mutations who had been treated with EGFR TKI(s) and who had at least one tumor specimen profiled via targeted next generation sequencing (OncoPanel). Duration of therapy (DOT) on first-line EGFR TKI and overall survival (OS) were assessed. Mutations associated with differential benefit to therapy were identified by comparing mutation rates in outliers with DOT or OS ≥75th percentile vs ≤25th percentile. Fisher’s exact test was used to calculate statistical significance, and the Benjamini-Hochberg method was used to correct for false discovery rate (FDR). Time to event outcomes were assessed with the Kaplan-Meier method.

      Result

      We identified 270 patients for inclusion in our cohort. 70% were female (190/270), 60% were never smokers (163/270), and median age was 62 (range 29-93). Sensitizing EGFR mutations were predominantly exon 19 deletion (51%, 138/270) or L858R (38%, 103/270). 94% of patients were treated with first-line erlotinib (253/270), and 30% received second-line osimertinib (82/270). The median DOT on first-line TKI was 12 months (range 0-72 months) and median OS was 28 months (range 1-133 months). Pre-treatment sequencing was available for 188 patients, 65 of whom also had documented assessment of resistance mechanism (T790M 78%, other 22%). Pre-existing concurrent TP53 mutations were associated with shorter DOT (median 10 vs 16 mo, p=0.0017), but there was no significant difference in OS (median 25 vs 36 mo, p=0.2) and no association with resistance mechanism (p=0.674). In addition to TP53, BCOR and SMARCA4 mutations were enriched in patients with shorter DOT, whereas MTOR mutations were enriched in patients with DOT in the top quartile, though these analyses did not pass FDR correction. Pre-treatment SMARCA4 mutations were more frequent in patients with survival in the bottom quartile (Fisher’s p=0.01), and were associated with decreased OS (median 32 vs 12 mo, log-rank p<0.0001).

      Conclusion

      Genomic features may contribute to differential outcomes in patients with EGFR-mutated NSCLC. In addition to TP53 mutations, pre-treatment SMARCA4 mutations may associate with worse outcomes in these patients.

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      MA09.11 - Mechanisms of Resistance to MET Tyrosine Kinase Inhibitors in Patients with MET Exon 14 Mutant Non-Small Cell Lung Cancer (Now Available) (ID 1421)

      15:15 - 16:45  |  Author(s): Lynette M Sholl

      • Abstract
      • Presentation
      • Slides

      Background

      Type I and II MET tyrosine kinase inhibitors (TKIs) are under development for patients with MET exon 14 mutant non-small cell lung cancer (NSCLC). Understanding the mechanisms driving resistance to MET TKIs is critical to design novel treatment strategies for this molecular subtype of NSCLC.

      Method

      Among patients with MET exon 14 mutant NSCLC treated with MET TKIs, pre- and post-TKI tumor tissue specimens and plasma samples were analyzed using next-generation sequencing (NGS) to explore genomic mechanisms of resistance upon disease progression.

      Result

      Between April 2014 to March 2019, 38 patients were treated with MET TKIs. Among these, paired samples from 15 individuals were evaluable for this study. Patients were treated with MET TKIs in the first-line (N=7; 46.7%), second-line (N=5; 33.3%), third-line (N=1; 6.7%) and fourth-line (N=2: 13.3%) setting. Eight patients were treated with one type I MET TKI and 7 patients received ≥2 MET TKIs. On target mechanisms of resistance were identified in 5 patients (33.3%), through secondary mutations in the MET tyrosine kinase domain (N=4) and MET amplification (N=1). Single MET kinase domain mutations D1228H/N were detected in 2 patients progressing on treatment with a type I MET TKI. In two cases, tumor tissue revealed only one resistance mutation (case #1 with Y1230H; case #2 with H1094Y), whereas paired plasma analysis demonstrated ≥3 resistance mutations in ctDNA (case #1 with G1163R, D1228N, Y1230H/S; case #2 with H1094Y, L1195F/V), reflecting the emergence of polyclonal on-target resistance. Off-target mechanisms of acquired resistance were identified in 7 patients treated with Type I MET TKI (46.7%) and involved amplification of EGFR (N=2), EGFR/HER2 (N=1), EGFR/HER3 (N=1), KRAS (N=1), EGFR/KRAS/BRAF (N=1), CCND1 (N=1). In 2 cases with bypass activation, sequential treatment with type II MET TKIs did not confer benefit. A concurrent NF1 mutation was present at baseline in a patient with primary resistance to MET TKI (6.7%). In 2 patients (13.3%), no genomic mechanisms of resistance were identified.

      Conclusion

      The landscape of resistance mechanisms to MET TKIs in NSCLC includes single and polyclonal secondary kinase domain mutations and bypass track activation by amplification of key oncogenes involving the ErbB/HER family of tyrosine kinase receptors and the MAPK signaling pathway. Given the complexity of resistance, therapeutic efforts to prevent acquired resistance in MET exon 14 mutant NSCLC should be developed.

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    MS02 - What Molecular Screening for Which Patients? (ID 65)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Targeted Therapy
    • Presentations: 1
    • Now Available
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      MS02.03 - Achieving Effective Lung Cancer Genotyping While Balancing Constrained Resources (Now Available) (ID 3444)

      10:30 - 12:00  |  Presenting Author(s): Lynette M Sholl

      • Abstract
      • Presentation
      • Slides

      Abstract

      Modern oncologic practice for patients with non-small cell lung carcinoma (NSCLC) demands real time data for an increasing numbers of tumor biomarkers. As a result, laboratories are embracing panel-based approaches to tumor molecular profiling, a trend that is facilitated by the adoption of next generation sequencing (NGS) assays. NGS assays may be designed for highly sensitive and focused detection of hotspot mutations (typically by amplicon sequencing) or broader, more comprehensive profiling for detection of a wide variety of alterations in oncogenes and tumor suppressor genes (typically by hybrid capture technology). There are benefits and drawbacks to both approaches. In general, amplicon sequencing offers speed and sensitivity but limited scope and a propensity for PCR-related artifacts that may adversely affect detection of certain mutation types. In contrast, hybrid capture techniques offer tremendous breadth, enabling capture of 100s of genes to whole genomes, but are limited by sensitivity and longer turnaround time.1 Preanalytic steps including sample acquisition, pathologist review to confirm sample adequacy, and nucleic acid extraction often comprise the majority of the turnaround time required to complete focused tumor tissue molecular profiling. Some assays have been optimized for turnaround times of just a few hours- these assays bypass the separate nucleic acid extraction step,2 but are limited by the few number of mutational targets detected, ultimately requiring the use of multiple simultaneous or sequential focused panels.3 This practice, while perhaps the optimal current model from the standpoint of patient care, may be financially prohibitive for many laboratories. This approach additionally requires careful stewardship of patient tissues, as the use of multiple competing assays and may lead to exhaustion of tumor tissue and incomplete tumor molecular profiling. For patients with limited tissue, a considered plan incorporating input from the treating physician, surgical pathologist, and molecular laboratorian should developed early in order to guide assay priority and ensure adequate tissue is available to confirm any unexpected or contradictory results. When the turnaround time for comprehensive large panel testing is clinically acceptable, this approach may be theoretically more cost effective and in most cases will deliver information for essential and emerging biomarkers.4 It is important to keep in mind, however, that even comprehensive DNA-based assays may lack optimal sensitivity for certain structural variants (fusions, large insertion-deletion events), and it may be necessary to couple these tests with focused RNA-based panels optimized for transcript fusion detection.5

      1. Rizzo JM, Buck MJ. Key principles and clinical applications of "next-generation" DNA sequencing. Cancer Prev Res (Phila). 2012;5(7):887-900.

      2. Ilie M, Butori C, Lassalle S, et al. Optimization of EGFR mutation detection by the fully-automated qPCR-based Idylla system on tumor tissue from patients with non-small cell lung cancer. Oncotarget. 2017;8(61):103055-103062.

      3. Lindeman NI, Cagle PT, Aisner DL, et al. Updated Molecular Testing Guideline for the Selection of Lung Cancer Patients for Treatment With Targeted Tyrosine Kinase Inhibitors: Guideline From the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology. J Mol Diagn. 2018;20(2):129-159.

      4. Sireci AN. Single Genes, Panels, and Next-Generation Sequencing Platforms: A Financial Perspective. Arch Pathol Lab Med. 2018;142(7):790-791.

      5. Benayed R, Offin M, Mullaney K, et al. High Yield of RNA Sequencing for Targetable Kinase Fusions in Lung Adenocarcinomas with No Mitogenic Driver Alteration Detected by DNA Sequencing and Low Tumor Mutation Burden. Clin Cancer Res. 2019.

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    OA03 - Systemic Therapies for SCLC: Novel Targets and Patients' Selection (ID 121)

    • Event: WCLC 2019
    • Type: Oral Session
    • Track: Small Cell Lung Cancer/NET
    • Presentations: 1
    • Now Available
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      OA03.07 - Immune-Related Adverse Events and Clinical Outcome to Anti PD-1 Axis Inhibition in SCLC: A Multicenter Retrospective Analysis (Now Available) (ID 2880)

      13:30 - 15:00  |  Author(s): Lynette M Sholl

      • Abstract
      • Presentation
      • Slides

      Background

      Immune-checkpoint inhibitors (ICIs) have shown promising activity in only a fraction of patients with small cell lung cancer (SCLC), and factors associated with clinical benefit are not well characterized. The development of immune-related adverse events (irAEs) may correlate with benefit from immune checkpoint inhibitors (ICIs) among patients with cancer. Whether an association exists between irAE development and improved clinical outcomes to ICIs in small cell lung cancer (SCLC) is unknown.

      Method

      We retrospectively analyzed data from five participating academic centers: the Dana-Farber Cancer Institute, East Carolina University, Columbia University, Beth Israel Deaconess Medical Center, and Johns Hopkins University. Patients with SCLC who received at least one dose of a programmed death (ligand) PD-(L)1 inhibitor alone or in combination with a cytotoxic T-lymphocyte associated protein 4 (CTLA-4) inhibitor were included in this study. To account for the time-dependent nature of irAE onset and clinical benefit from immunotherapy, we identified patients with early irAEs (defined as those occurring within 6 weeks of ICI treatment initiation) and performed a landmark analysis at this time point.

      Result

      Among 157 patients treated with ICIs, 65 (41.4%) experienced at least one irAE. Median time to the first irAE onset was 28 days (IQR:15-56). Baseline clinicopathologic characteristics were well balanced between patients who developed irAEs and those who did not. Median tumor mutational burden (TMB) was significantly higher among patients with irAEs compared to those without (14.4 vs 8.4 mutations/megabase [mut/Mb], P <0.01). Patients who developed at least one irAE had a significantly higher objective response rate (26.3% versus 3.3%, P <0.001), and significantly longer median progression-free survival (mPFS, 4.1 vs 1.3 months, HR: 0.30 [0.20-0.43, P <0.001]) and median overall survival (mOS, 14.1 vs 2.9 months, HR: 0.32 [0.21-0.48], P <0.001). The proportion of patients who were progression-free at 6, 9, and 12 weeks was significantly higher in patients who developed early irAEs compared to those who did not develop early irAEs (6 weeks: 89.5% vs 69.5%, P =0.01; 9 weeks: 71.1% vs 40%, P =0.001; 12 weeks: 65.8% vs. 31.6%, P <0.001). The median TMB was also significantly higher in patients who developed early irAEs (14.5 vs 8.7 mut/Mb, P <0.01).

      Conclusion

      Patients with SCLC treated with ICIs who developed early irAEs had a higher TMB and enhanced antitumor responses compared to those who did not develop irAEs. Whether a higher TMB is associated with the development of irAEs remains to be determined mechanistically.

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    P1.04 - Immuno-oncology (ID 164)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Immuno-oncology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/08/2019, 09:45 - 18:00, Exhibit Hall
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      P1.04-04 - DNA Damage Response Gene Alterations Are Associated with High Tumor Mutational Burden and Clinical Benefit from PD-1 Axis Inhibition in NSCLC (Now Available) (ID 2620)

      09:45 - 18:00  |  Author(s): Lynette M Sholl

      • Abstract
      • Slides

      Background

      DNA damage response (DDR) gene alterations are associated with increased tumor infiltrating lymphocytes, higher genomic instability, and higher tumor mutational burden (TMB) in cancer. Whether DDR alterations are associated with benefit from immune-checkpoint inhibitors (ICIs) in non-small cell lung cancer (NSCLC) is unknown.

      Method

      Clinicopathologic and genomic data were collected from patients (pts) with advanced NSCLC at the Dana-Farber Cancer Institute treated with PD-(L)1 inhibitors. Targeted next-generation sequencing (NGS) by OncoPanel was used to determine DDR gene mutation status and TMB. All loss-of-function alterations in DDR genes (including nonsense, frameshift, or splice site) were classified as pathogenic. Missense mutations were manually evaluated and classified as pathogenic if considered to be deleterious in the Catalogue of Somatic Mutations in Cancer (COSMIC) and ClinVar databases, as well as the PolyPhen-2 (Polymorphism Phenotyping v2) functional prediction tool.

      Result

      Of 223 pts with successful NGS who received ICIs, 116 (52.0%) were identified as having pathogenic DDR mutations (DDRpos) with alterations in the following genes: FANC genes (20%) ATM (13.9%), POL genes (11%), ERCC genes (8%), BRCA1/2 (8%), MLH1/MSH2/MSH6 (7%), CHEK1/2 (7%), RAD genes (6%), ATR (5%), BRIP1 (3%), XRCC genes (3%), BARD1 (2%), PMS (2%), NEIL (2%), BAP1 (1%), PALB2 (1%). DDRpos and DDR negative (DDRneg) groups were well balanced in terms of age, gender, histology, performance status (PS), smoking status, baseline presence of brain metastasis. The median TMB was significantly higher in the DDRpos group compared to the DDRneg group (12.9 vs 8.3 mutations/megabase [mut/Mb], P < 0.001), including among never smokers (11.0 vs 6.8 mut/Mb, P = 0.02). No difference in median PD-L1 expression was observed between groups (50% vs 50%, P = 0.52). Compared to DDRneg pts (N=107), DDRpos pts had a significantly higher objective response rate (30.4% vs 16.8%, P = 0.001), longer median progression-free survival (4.3 vs 2.3 months, HR: 0.64 [95%CI: 0.48-0.86], P = 0.003) and median overall survival (16.5 vs 11.2 months, HR: 0.62 [95%CI: 0.44-0.88], P = 0.008) with PD-(L)1 therapy. After adjusting for ECOG PS, smoking status, baseline brain metastasis, and line of therapy, DDRpos status was associated with significantly longer PFS (HR: 0.64 [0.48-0.86], P < 0.01) and OS (HR: 0.58 [95%CI: 0.41-0.83], P < 0.01) in multivariate analysis.

      Conclusion

      Pathogenic DDR alterations are frequent in NSCLC and are associated with higher TMB and improved clinical outcomes among NSCLC pts treated with PD-1 axis inhibition.

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    P2.04 - Immuno-oncology (ID 167)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Immuno-oncology
    • Presentations: 2
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.04-27 - Clinical Implementation of Multiplex Immunofluorescence to Characterize Tumor Immune Status in Lung Cancer Patients (Now Available) (ID 2925)

      10:15 - 18:15  |  Presenting Author(s): Lynette M Sholl

      • Abstract
      • Slides

      Background

      Tumor cell PD-L1 positivity by immunohistochemistry (IHC) enriches for response with PD-(L)1 inhibitors in patients with non-small cell lung carcinoma (NSCLC). However, PD-L1 IHC has limited positive and negative predictive value and does not provide information about the immune effector cell population in the tumor environment. Multiplex immunofluorescence (MIF) can be used to simultaneously characterize checkpoint proteins and immune cell infiltrates on a single tumor slide. MIF is not, however, routinely used in clinical practice. We operationalized and launched prospective MIF for lung cancer patients.

      Method

      Patients were consented to an institutional protocol for tumor sequencing and immunoprofiling. Samples were submitted for MIF reflexively following a diagnosis of lung cancer on any in-house core biopsy or resection specimen. Slides were reviewed by a pathologist and imaging scientist to confirm tumor adequacy and three to six representative 20X fields of view that included tumor and tumor-stroma interface were selected for scoring. Automated staining for AE1/AE3, PD-L1, PD-1, CD8, FoxP3 and DAPI was carried out on a Leica BOND RX Autostainer and imaged using the Polaris imaging system (PerkinElmer). Under pathologist supervision, biomarkers were quantified in each region at a single cell level using the Inform Advanced Image Analysis Software (PerkinElmer). An automated reporting system calculated a PD-L1 tumor proportion score (TPS) and immune cell density across the analyzed regions.

      Result

      To date, 80 samples have been received for analysis (40% biopsies and 60% resections), of which 78 (98%) were imaged successfully. Average turnaround time from receipt of specimen to complete reporting was 25 days. PD-L1 was considered positive (TPS >50%) in 4 (5%), low positive (1-49%) in 42 (55%), and negative (<1%) in 32 (41%). CD8+/PD1+ density ranged from 0 to >800/mm2 (median 59) and FOXP3+ cells from 2 to >700/mm2 (median 59); both showed a broad standard deviation, consistent with heterogeneity in the tumor and adjacent stroma. Nine (11%) tumors showed a pattern of adaptive immune resistance (so-called “hot” tumors), defined as CD8+/PD1+ density greater than the median and at least low positive PD-L1 TPS.

      Conclusion

      Multiplex immunofluorescence and pathologist-guided image analysis of fixed tissue specimens can be integrated into clinical practice with a low rate of failure and acceptable turn-around time to identify unique immunologic subsets of lung cancer. Limitations of data storage and analysis speed require focused field selection, therefore optimization of the scored area(s) is essential to ensure accurate tumor immune classification. Studies to determine the feasibility of use of MIF for selection of patients for immunotherapy are ongoing.

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      P2.04-32 - Comparison of Clinicopathological and Genomic Characteristics Between NSCLCs with a PD-L1 Tumor Proportion Score of ≥90% vs &lt;1% (Now Available) (ID 2618)

      10:15 - 18:15  |  Author(s): Lynette M Sholl

      • Abstract
      • Slides

      Background

      Determinants of PD-L1 expression in non-small cell lung cancer (NSCLC) are poorly defined. To identify characteristics associated with high vs. absent PD-L1 expression, we compared clinicopathologic and genomic features of NSCLCs at the two ends of PD-L1 expression spectrum: a PD-L1 tumor proportion score (TPS) of ≥90% or a PD-L1 TPS of <1%.

      Method

      We retrospectively collected clinicopathologic and genomic data (via targeted NGS) from consecutive NSCLC patients who had consented to an IRB-approved correlative research study and whose tumor PD-L1 TPS was either ≥90% or <1%. Single nucleotide variations, insertions/deletions, and copy number alterations were compared using Fisher’s exact test. Tumor mutational burden (TMB) was compared using Mann-Whitney test.

      Result

      421 NSCLCs with PD-L1 TPS ≥90% (N=133) or <1% (N=288) and successfully performed NGS were identified. There was no difference in age, sex, histology, or stage at diagnosis between the two groups. Patients with a PD-L1 TPS of ≥90% were more likely to be smokers (86.5% vs 76.4%; P=0.02) compared to patients with a PD-L1 TPS of <1%, and tumors in the PD-L1 TPS ≥90% group had higher TMB (10.89 vs 8.47 mutations/megabase; P=0.004) than those in the PD-L1 TPS <1% group. Tumors in the PD-L1 TPS ≥90% group were more likely to have KRAS (47.3% vs 31.3%; P=0.002), MET exon 14 (9.6% vs 2.1%; P=0.003), and TP53 mutations (71.0% vs 49.7%; P<0.001) than those in the PD-L1 TPS <1% group. Compared to the PD-L1 TPS ≥90% group, the PD-L1 TPS <1% group was more likely to have EGFR (23.6% vs 8.2%; P<0.001) and STK11 (23.4% vs 5.0%; P<0.001) mutations, as well as the absence of known oncogenic driver mutations (35.2% vs 24.8%; P=0.04). Chromosomal gain alterations (amplification or copy number gain) of the 9p24.1 locus, where the PD-L1, PD-L2, and JAK2 genes are located, were more common in the PD-L1 TPS ≥90% group than in the PD-L1 TPS <1% group (11.4% vs 2.8%, respectively; P<0.001). Chromosomal loss alterations (copy loss or deletion) of the 9p24.1 locus were more common in the PD-L1 TPS <1% than in the PD-L1 TPS ≥90% group (27.5% vs 3.8%, respectively; P<0.001). A repeated biopsy case showed acquired loss PD-L1 expression (PD-L1 TPS changed from 90% to 0%) with concomitant acquired loss of the 9p24.1 locus.

      Conclusion

      High PD-L1 expression in NSCLC is associated with tobacco use, high TMB, gain of the 9p24.1 locus and mutations in KRAS, MET exon 14, and TP53. PD-L1 negativity is associated with never smoking status, low TMB, loss of the 9p24.1 locus, mutations in EGFR and STK11, and the absence of oncogenic driver mutations.

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    P2.09 - Pathology (ID 174)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Pathology
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.09-24 - IASLC Global Survey for Pathologists on PD-L1 Testing for Non-Small Cell Lung Cancer (ID 906)

      10:15 - 18:15  |  Author(s): Lynette M Sholl

      • Abstract
      • Slides

      Background

      PD-L1 immunohistochemistry (IHC) is now performed for advanced non-small cell lung cancer (NSCLC) patients to examine their eligibility for pembrolizumab treatment, as well as in Europe for durvalumab therapy after chemoradiation for stage III NSCLC patients. Four PD-L1 clinical trial validated assays (commercial assays) have been FDA/EMA approved or are in vitro diagnostic tests in multiple countries, but high running costs have limited their use; thus, many laboratories utilize laboratory-developed tests (LDTs). Overall, the PD-L1 testing seems to be diversely implemented across different countries as well as across different laboratories.

      Method

      The Immune biomarker working group of the IASLC international pathology panel conducted an international online survey for pathologists on PD-L1 IHC testing for NSCLC patients from 2/1/2019 to 5/31/2019. The goal of the survey was to assess the current prevalence and practice of the PD-L1 testing and to identify issues to improve the practice globally. The survey included more than 20 questions on pre-analytical, analytical and post-analytical aspects of the PDL1 IHC testing, including the availability/type of PD-L1 IHC assay(s) as well as the attendance at a training course(s) and participation in a quality assurance program(s).

      Result

      344 pathologists from 310 institutions in 64 countries participated in the survey. Of those, 38% were from Europe (France 13%), 23% from North America (US 17%) and 17% from Asia. 53% practice thoracic pathology and 36%, cytopathology. 11 pathologists from 10 countries do not perform PD-L1 IHC and 7.6% send out to outside facility. Cell blocks are used by 75% of the participants and cytology smear by 9.9% along with biopsies and surgical specimens. Pre-analytical conditions are not recorded in 45% of the institutions. Clone 22C3 is the most frequently used (61.5%) (59% with the commercial assay; 41% with LDT) followed by clone SP263 (45%) (71% with the commercial assay; 29% with LDT). Overall, one or several LDTs are used by 57% of the participants. A half of the participants reported turnaround time as 2 days or less, while 13% reported it as 5 days or more. Importantly, 20% of the participants reported no quality assessment, 15%, no formal training session for PD-L1interpretation and 14%, no standardized reporting system.

      Conclusion

      There is marked heterogeneity in PD-L1 testing practice across individual laboratories. In addition, the significant minority reported a lack of quality assurance, formal training and/or standardized reporting system that need to be established to improve the PD-L1 testing practice globally.

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