Publications

<p>Consort diagram describing samples disposition in the study.</p>

Abstract Three classes of BCMA-directed therapy (BDT) exist: antibody drug-conjugates (ADCs), CAR-T, and T-cell engagers (TCEs), each with distinct strengths and weaknesses. To aid clinicians in selecting between BDTs, we reviewed myeloma patients treated at Mayo Clinic with commercial or investigational BDT between 2018-2023. We identified 339 individuals (1-exposure = 297, 2-exposures = 38, 3-exposures = 4) who received 385 BDTs (ADC = 59, TCE = 134, CAR-T = 192), with median follow-up of 21-months. ADC recipients were older, with more lines of therapy (LOT), and penta-refractory disease. Compared to ADCs, CAR-T (aHR = 0.29, 95%CI = 0.20–0.43) and TCEs (aHR = 0.62, 95%CI = 0.43–0.91) had better progression-free survival (PFS) on analysis adjusted for age, the presence of extramedullary (EMD), penta-refractory disease, multi-hit high-risk cytogenetics, prior BDT, and the number of LOT in the preceding 1-year. Likewise, compared to ADCs, CAR-T (aHR = 0.28, 95%CI = 0.18–0.44) and TCEs (aHR = 0.60, 95%CI = 0.39–0.93) had superior overall survival. Prior BDT exposure negatively impacted all classes but was most striking in CAR-T, ORR 86% vs. 50% and median PFS 13-months vs. 3-months. Of relapses, 54% were extramedullary in nature, and a quarter of these cases had no history of EMD. CAR-T demonstrates superior efficacy and where feasible, should be the initial BDT. However, for patients with prior BDT or rapidly progressive disease, an alternative approach may be preferable.

Multiple Myeloma (MM) accounts for 1-2% of all malignancies but is the second most common hematological malignancy. It is characterized by a proliferation of malignant plasma cells. The treatment paradigm of MM in Australia is traditionally hospital-based, complex, and costly. While MM comprises 1-2% of cancer diagnoses, it appears in the top 10 cancer diagnoses requiring hospital admission. The cumulative time spent receiving treatment is a significant burden for patients. The ability to receive treatment at home and maximize time away from hospital-based settings is a key preference for patients receiving anticancer therapies over a prolonged period of time.The Peter MacCallum Cancer Centre and Royal Melbourne Hospital's combined Clinical Hematology Unit has collaborated with their Hospital in the Home departments to develop several innovative programs to address this.We describe our current active programs and potential developments in home-based MM therapy.We have enabled large numbers of patients to receive complex therapies in their own home and the COVID-19 pandemic has increased the pace of the roll out without any compromise in safety. We anticipate that the next raft of immunotherapies will be able to transition into the @Home treatment setting in the coming years.

Abstract Background Existing methods to detect tumor signal in liquid biopsy have focused on the analysis of nuclear cell-free DNA (cfDNA). However, non-nuclear cfDNA and in particular mitochondrial DNA (mtDNA) has been understudied. We hypothesize that an increase in mtDNA in plasma could reflect the presence of cancer, and that leveraging cell-free mtDNA could enhance cancer detection. Results We survey 203 healthy and 664 cancer plasma samples from three collection centers covering 12 cancer types with whole genome sequencing to catalogue the plasma mtDNA fraction. The mtDNA fraction is increased in individuals with cholangiocarcinoma, colorectal, liver, pancreatic, or prostate cancer, in comparison to that in healthy individuals. We detect almost no increase of mtDNA fraction in individuals with other cancer types. The mtDNA fraction in plasma correlates with the cfDNA tumor fraction as determined by somatic mutations and/or copy number aberrations. However, the mtDNA fraction is also elevated in a fraction of patients without an apparent increase in tumor-derived cfDNA. A predictive model integrating mtDNA and copy number analysis increases the area under the curve (AUC) from 0.73 when using copy number alterations alone to an AUC of 0.81. Conclusions The mtDNA signal retrieved by whole genome sequencing has the potential to boost the detection of cancer when combined with other tumor-derived signals in liquid biopsies.

Abstract Prostate cancer (PCa) has a profoundly immunosuppressive microenvironment, we hypothesized that radiation therapy would break this immune suppression. To investigate this, we performed high-throughput immune cell subset analysis, and gene expression profiling of pre-versus post-radiation tissue in a cohort of patients with localized disease that received high dose-rate brachytherapy (HDRBT). We resolved tumor and non-tumor zones in our spatial analysis to explore what drives the immunological response. Nanostring immune profiling revealed numerous immune checkpoint molecules were stimulated in response to HDRBT (e.g. B7-H3, CTLA4, PDL1 and PDL2). A published 16-gene tumor inflammation signature (TIS) gene profiling of immune activation states (high: hot , intermediate and low: cold ) showed that most tissues possessed a low TIS pre-HDRBT. Crucially, HDRBT converted 80% of these ‘cold’-phenotype tumors into an ‘intermediate’ or ‘hot’ class. We used digital spatial profiling to show these HDRBT-induced changes in prostate TIS scores were derived from the non-tumor regions. Furthermore, these changes in TIS were also associated with pervasive changes in immune cell density and spatial relationships – in particularly between T cell subsets and antigen presenting cells. We identified increased density of CD4 + FOXP3 + T cells, CD68 + macrophages and CD68 + CD11c + dendritic cells in response to HDRBT. The only subset change in tumor zones was PDL1 + macrophages. While these immune responses were heterogeneous, HDRBT induced significant changes in immune cell associations, including a gained T cell and HMWCK + PDL1 + interaction in tumor zones. In conclusion, we showed HDRBT has a clear impact in converting “cold” prostate tumors into more immunologically activated “hot” tissues, with accompanying spatially-organized immune infiltrates and signaling changes. Understanding and potentially harnessing these changes will have widespread implications for the future treatment of localized PCa and the possible use of combination immunotherapies.

<div>Abstract<p><b>Purpose:</b> Precise detection of copy number aberrations (CNA) from tumor biopsies is critically important to the treatment of metastatic prostate cancer. The use of targeted panel next-generation sequencing (NGS) is inexpensive, high throughput, and easily feasible, allowing single-nucleotide variant calls, but CNA estimation from this remains challenging.</p><p><b>Experimental Design:</b> We evaluated CNVkit for CNA identification from amplicon-based targeted NGS in a cohort of 110 fresh castration-resistant prostate cancer biopsies and used capture-based whole-exome sequencing (WES), array comparative genomic hybridization (aCGH), and FISH to explore the viability of this approach.</p><p><b>Results:</b> We showed that this method produced highly reproducible CNA results (<i>r</i> = 0.92), with the use of pooled germline DNA as a coverage reference supporting precise CNA estimation. CNA estimates from targeted NGS were comparable with WES (<i>r</i> = 0.86) and aCGH (<i>r</i> = 0.7); for key selected genes (<i>BRCA2, MYC, PIK3CA, PTEN</i>, and <i>RB1</i>), CNA estimation correlated well with WES (<i>r</i> = 0.91) and aCGH (<i>r</i> = 0.84) results. The frequency of CNAs in our population was comparable with that previously described (i.e., deep deletions: <i>BRCA2</i> 4.5%; <i>RB1</i> 8.2%; <i>PTEN</i> 15.5%; amplification: AR 45.5%; gain: MYC 31.8%). We also showed, utilizing FISH, that CNA estimation can be impacted by intratumor heterogeneity and demonstrated that tumor microdissection allows NGS to provide more precise CNA estimates.</p><p><b>Conclusions:</b> Targeted NGS and CNVkit-based analyses provide a robust, precise, high-throughput, and cost-effective method for CNA estimation for the delivery of more precise patient care. <i>Clin Cancer Res; 23(20); 6070–7. ©2017 AACR</i>.</p></div>

Objective: To investigate the early warning and prognostic evaluation of fecal calprotectin (FC), D-lactic acid, and bedside gastrointestinal ultrasound (B-GIUS) data for acute gastrointestinal injury (AGI) in sepsis patients. Main Method: Sepsis patients were grouped based on the presence or absence of AGI into AGI and non-AGI groups. Healthy volunteers of the same period were selected as the control group. FC, B-GIUS data, D-lactic acid, etc. were collected on the 1st, 3rd and 7th days of admission. Twenty-eight-day mortality was recorded. Main Results: FC, D-lactic acid levels, gastric antrum cross-sectional area, and small intestine wall thickness were significantly increased in group A and B (P < 0.05); furthermore, inner-to-outer diameter ratio and cross-sectional area of small intestine were lower than those in the control group (P < 0.05). FC, D-lactic acid, gastric antrum cross-sectional area and small intestine wall thickness in AGI group were higher than those in non-AGI group (P < 0.05). Inner-to-outer diameter ratio and cross-sectional area of small intestine in AGI group were smaller than those in non-AGI group (P < 0.05). There was no difference in the thickness, inner-to-outer diameter ratio nor the cross-sectional area ratio of colon between AGI and non-AGI groups (P > 0.05). AUC for D-lactic acid was 0.881, which was higher than FC's (0.74). When the D-lactic acid cutoff value was 22.16 μmol/L, the sensitivity was 77.9% and the specificity was 92% for the prediction of AGI in sepsis. AUC for the cross-sectional area of the gastrointestinal antrum was 0.657, which was higher than the small intestine thickness's (0.629). When the gastric antrum cross-sectional area was larger than 4.20 cm2, the sensitivity was 64% and the specificity was 65.3%. Conclusion: D-Lactic acid and FC were early diagnostic indicators for sepsis with AGI, and D-lactic acid was the superior indicator. The gastric antrum cross-sectional area and the small intestine wall thickness had an early warning effect, and the prediction of the gastric antrum cross-sectional area was superior to that of the latter. Because it is non-invasive and convenient, B-GIUS can help in the diagnosis of sepsis with AGI.

TPS264 Background: High-risk localised prostate cancer (HRCaP) is treated by radical prostatectomy (RP) or radiotherapy. Despite curative intent, a significant number of men will progress with metastatic disease or local recurrence. Lutetium-177 radiolabelled to the small molecule PSMA-617 targeting prostate-specific membrane antigen (Lu-PSMA) has proven efficacious in men with metastatic castration-resistant prostate cancer who have progressed after standard-of-care. The LuTectomy trial evaluates whether administration of Lu-PSMA before radical prostatectomy in men with HRCaP will deliver high doses of radiation to the prostate and involved lymph nodes. It also aims to assess the feasibility, safety profile and oncological efficacy of Lu-PSMA. Methods: Lutectomy is an open-label, phase I/II non-randomised clinical trial. 20 men with HRCaP defined by European Association of Urology who are scheduled for RP and pelvic lymph node dissection (PLND) will be recruited. All men will have high PSMA-avidity with a standardised uptake value (SUVmax) of ≥ 20 on 68 Ga-PSMA PET/CT. The initial 10 participants will receive one cycle of 5GBq Lu-PSMA intravenously and the latter 10 men will receive two cycles of 5GBq Lu-PSMA per cycle six weeks apart. RP with PLND will be performed six weeks later. Participants will be followed up for three years. The primary outcome is to determine the radiation absorbed dose in the prostate and involved lymph nodes. Three-time point quantitative single-photon emission computed tomography (SPECT/CT) will be used to estimate radiation dosimetry using a voxelated technique incorporating partial volume correction. Marrow absorbed dose will also be evaluated using serial blood measures to model pharmacokinetic clearance with a multi-phase exponential model. Translational research samples will include the original biopsy, prostatectomy specimen and plasma/whole blood samples. Secondary objectives include evaluation of the PSMA PET/CT imaging response (defined by SUVmax decline &gt;30%), PSA response, pathological response following Lu-PSMA, adverse effects of Lu-PSMA, surgical safety, and health-related quality of life. Post estimates for time-to-event endpoints will be estimated using the Kaplan-Meier method. The first patient was recruited in July 2020 and recruitment is expected to take up to two years. ClinicalTrials.gov Identifier: NCT04430192. Funding: Movember and Medical Research Future Fund (MRFF), Endocyte Inc., a Novartis Company, E.J. Whitten Foundation. Clinical trial information: NCT04430192.

340 Background: Prostate cancer is frequently cured with high-dose rate brachytherapy as a front-line treatment. However, a significant number unfortunately develop intrinsic resistance. Although considered to be an immune-excluded tissue, immune responses are implicated in driving tumour-eradication in prostate cancer. This has not been proven, and yet is used as the rationale for numerous clinical trials combining radiation and immunotherapies. We hypothesise that there is a predictable but differential relationship between radiation and the immune responses in prostate cancer that could be used to fulfil a clinical need - identifying patients that would benefit from immune intervention in conjunction with radiation. Methods: We present here the results of comprehensive immunological profiling of a cohort of world-unique pre- and post-radiation tissues from 24 patients (RadBank cohort). These were assessed using pathological classification, tissue segmentation (cancer/surrounding stroma), multiplex IHC, gene expression profiling, T-cell receptor sequencing, and spatial computational analysis. Results: Our data resolved three classes of prostate cancer tissue based on immune infiltrate level, immune-activation and -checkpoint gene signatures, spatial clustering and T cell clone sequencing: We have begun to resolve clear patient and clinical classifiers based on immune responses to radiation, and identified patients groups likely to benefit from immune therapy alongside radiation. Conclusions: Importantly, these classifications are associated with baseline gene expression profiles that may be used for pre-clinical stratification and more sophisticated treatment paradigms.

Supplementary Figure from Tumor Genomic Testing for &gt;4,000 Men with Metastatic Castration-resistant Prostate Cancer in the Phase III Trial PROfound (Olaparib)