B cells within the tumor aid response in patients with melanoma, sarcoma, and renal cell carcinoma

Here's a link to a new report out of MD Anderson:  B-cell enrichment predictive of immunotherapy response in melanoma, sarcoma and kidney cancer

Which states, in part:

Studies published today in Nature conclude that enrichment of B cells, a type of immune cell known for producing antibodies, in TLS was predictive of response to checkpoint blockade in patients with melanoma, soft-tissue sarcomas, and renal cell carcinomas.

Checkpoint inhibitors offer the potential for long-term survival to patients across many cancer types, but not all benefit equally. Researchers previously have identified several useful biomarkers of response, which are helpful in identifying patients that may or may not benefit from checkpoint blockade.  The current studies conclude that the presence of B cells and their location within TLS, which act as a lymph node within the tumor, is critical for response to checkpoint blockade, suggesting a dynamic interaction between several components of the immune system.

Mature B cells in tumors of responders suggest active role in tumor immune response

An MD Anderson-led study found that B-cell markers were the most differentially expressed genes in responders relative to non-responders, and B cells in the tumors of responders appeared to be more mature and specialized. These findings were first presented at the 2019 American Association for Cancer Research Annual Meeting.  “These findings open up a whole new area ― that B cells are actually big drivers in cancer immunotherapy, specifically checkpoint blockade,” said corresponding author Jennifer Wargo, M.D... “This could lead us to important biomarkers for therapy response as well as potentially new therapeutic options.”

The team analyzed samples from patients with advanced melanoma receiving neoadjuvant, or pre-surgical, checkpoint inhibitors as part of a clinical trial sponsored by MD Anderson’s Melanoma Moon Shot...  The researchers also studied a group of patients with metastatic RCC being treated with neoadjuvant checkpoint blockade...   Tumor samples were collected from patients at baseline and during treatment ...

In each cohort, the expression of B cell-related genes was significantly higher in responders and was predictive of response to checkpoint blockade. These findings were further corroborated in an analysis of curated melanoma samples from The Cancer Genome Atlas, in which high expression of B-cell markers was associated with significantly improved overall survival.

“These data indicate the importance of cell types other than T cells, such as B cells, in the anti-tumor immune responses generated by immune checkpoint therapies,” said Sharma. “There is a great need to identify biomarkers of response to therapy, and these data may allow for future studies focused on developing composite biomarkers that represent both the T- and B-cell responses.”

The researchers determined that B cells were localized in the TLS, and the density of B cells and TLS in the tumor was higher in responders. Further analysis of these infiltrating B cells showed that those in responders expressed more markers of mature and differentiated B cells, such as memory B cells and plasma cells.

“Through these studies, we find that B cells are not just innocent bystanders, but are themselves contributing in a meaningful way to the anti-tumor immune response,” said first author Beth Helmink, M.D., Ph.D., fellow in Surgical Oncology.  [Red highlight = mine]  

So - news, but not news.  Meaning we've long known that there is a wide array of tumor markers and cells that determine response - whether these bits and bobs block the immune system and work to protect the tumor or facilitate immune response and try to do away with tumors in our body.  It isn't  surprising that B cells contribute to that as well.

Here are a zillion prior posts on such markers and cells, which begins with this from 2016:  Biomarkers - blood components, circulating tumor cells AND of the tumor itself Biomarkers. Sounds important. What are they? What can they really tell us?

We know that everything from floating bits of DNA in our blood stream, to antigens, to eosinophils, to the absolute number of monocytes and lymphocytes, to neutrophils, to t cells, to myeloid derived suppressor cells can help or hurt us in the fight to rid ourselves of melanoma and other cancers.  Speaking of MDSC - here's a bit of a definition:  MDSC; the Most Important Cell You Have Never Heard Of  However, if you are Jeff Weber or a reader of this blog - you have!!!

Here are a few reports on the mystery of the MDSC:  Markers for response to immunotherapy: Increased eosinophils = good. Increased Myeloid Suppressor cells = not so good. 

In fact, in looking at t-regs from the ratties in my study, from this report put out in 2014, My Nivo (Opdivo) trial - first dose - 4 years ago 12/29/2010 - thoughts... it was noted that: 

MDSC  (myeloid derived suppressor cells)
"There was a trend towards lower baseline MDSC levels in non-relapsing patients compared to relapsing patients."  This bit of stuff and such along with other Treg/Tcell data comes your way thanks to us ratties sitting through leukapheresis twice during the trial. However, this is a bit I'm pretty psyched about.  There is talk among melanoma big dogs that combining anti-PD1 with MDSC or T-reg depletion would make it more effective.  I think that holds real promise.  Though...once again...despite my blood and services having been rendered....I have no idea what my MDSC levels were.  Still...I think this could be a real boon to future patients.

So, YES!  Let's tweak our tumor battle field.  Let's boost the cells that help us and diminish those that don't.  I am confident that these tiny bits and bobs play a huge role in the lives of human ratties who respond to immunotherapy and those who don't.  And, yes, MD Anderson, I've written about your Moon Shot, too - in 2012 ~ Melanoma. Moon Shot. Curiosity. Will.i.am. The best 5th grade teacher in the world.

C'mon Man!!!  It's 2020!!  While great strides have been made, we've got a long way to go!  So let's get there! - c

Biomarkers - blood components, circulating tumor cells AND of the tumor itself

Biomarkers.  Sounds important.  What are they?  What can they really tell us? 

Researchers have been seeking to find a connection between nonspecific biomarkers (things we ALL have circulating in our blood) like LDH, various white blood cells (neutrophils and monocytes - whether as an absolute count or as a neutrophil to lymphocyte ratio), myeloid-derived suppressor cells (MDSCs) and T-regs (See post with links about all that here:   Blood markers associated with clinical outcomes).  And while many meaningful correlations have been drawn between these components and response to treatment (or lack thereof); the fact that they are all affected by numerous circumstances other than melanoma and its treatment, create limitations in the clarity with which they can be used to PREDICT responses.

With recent scientific advances, PCR testing (Polymerase chain reaction) has become more efficient and cost-effective, allowing labs to copy or "amplify" small segments of DNA or RNA though screening blood or other biological specimens.  This ability allows the cellular identification of whatever may be floating in that blood sample....whether it is a virus or fungus, or actual bits and pieces of tumor cells themselves, to allow a determination of  disease burden, prognosis, and response to treatment.  Here is an earlier post:  Circulating tumor cells: how they may eventually impact melanoma diagnosis and evaluation of response

Now there are these reports:

Liquid biopsy utility for the surveillance of cutaneous malignant melanoma patients.  Haung and Hoon.  Mol Oncol. 2015 Dec 17.

Cutaneous melanoma is one of the highest incident-rate cancers with increasing prevalence in Western societies. Despite the advent of new approved therapeutics, the 5-year overall survival rate of stage IV melanoma patients remains below 15%. Current treatments for late stage disease have shown higher efficacy when treated at a lower disease burden. Thus, blood-based biomarkers capable of detecting melanoma prior to clinically evident distant metastasis, will improve the treatment and outcomes for melanoma patients. To that end, effective treatment of melanoma necessitates identification of patients at risk for developing distant metastases. Furthermore, employing blood biomarkers that monitor cancer progression over the course of treatment is a promising solution to post-treatment drug resistance often developed in melanoma patients. Non-invasive blood biomarker assays allow for regular dynamic monitoring of disease. "Liquid Biopsy" of blood, which exploits circulating tumor cells (CTCs), cell-free circulating tumor DNA (ctDNA) and cell-free circulating microRNA (cmiRNA), has been shown to detect prognostic factors for relapse in AJCC stage III and stage IV melanoma patients. Moreover, molecular characterization of CTC and analysis of various forms of ctDNA present promising potential in development of individualized therapy for melanoma patients. New approaches such as massive parallel sequencing (MPS) provide a comprehensive view of the disease progression, allowing for the selection of therapeutic options for individual patients. With advancements of improving molecular assays, liquid biopsy analysis as a powerful, routine clinical assay for melanoma patients, is highly promising prospective.

Circulating melanoma cells as a potential biomarker to detect metastasis and evaluate prognosis.  Hida, Yoneta, Wakamatsu, et al.  Australas J Dermatol. 2016 Mar 1.

TNM staging is mainly used to evaluate the prognosis of melanoma patients. Serum biomarkers such as 5-S-cysteinyldopa (5-S-CD) have occasionally been used but most do not respond until the tumour burden becomes high. Recently, circulating melanoma cells (CMC) have been reported as a possible new biomarker to detect metastasis, monitor treatment response and predict prognosis. The object of this exploratory study was to evaluate the efficacy of CMC to detect metastasis and predict prognosis by cross-sectional and prospective observational analyses, respectively. Altogether 15 patients with stages II-IV melanoma were enrolled and CMC were enumerated by CellSearch system with cut-off values of two cells/7.5 mL. Serum 5-S-CD and lactate dehydrogenase (LDH) were also measured. The sensitivity of CMC and 5-S-CD for the detection of metastasis was 33 and 50%, respectively. The combination of CMC and 5-S-CD showed a sensitivity of 67%, the best performance among CMC, 5-S-CD, LDH and any combination of two of the markers. Additionally, a 30-month prospective observation showed that CMC could segregate patients with poorer prognosis. The median survival time for the patients with less than 2 CMC and those with greater than or equal to 2 CMC was 19.5 and 4.5 months, respectively. The limitation of this study is the small sample size. These preliminary results indicate CMC may complement the efficacy of 5-S-CD to detect metastasis and can be a prognostic marker. Although there is still room for improvement to maximize the sensitivity, the CellSearch system is reproducible, standardized and suitable for multi-center studies.

Then, there's the examination of the properties of the tumor sample itself.  This article talks about looking at the tumor in regard to how well it is being recognized by the immune system....specifically t-cells:
 

Melanoma-specific MHC-II expression represents a tumour-autonomous phenotype and predicts response to anti-PD-1/PD-L1 therapy.  Johnson, Estrada, Salgado, Sosman, et al.  Nat Commun.  2016 Jan 29.

Anti-PD-1 therapy yields objective clinical responses in 30-40% of advanced melanoma patients. Since most patients do not respond, predictive biomarkers to guide treatment selection are needed. We hypothesize that MHC-I/II expression is required for tumour antigen presentation and may predict anti-PD-1 therapy response. In this study, across 60 melanoma cell lines, we find bimodal expression patterns of MHC-II, while MHC-I expression was ubiquitous. A unique subset of melanomas are capable of expressing MHC-II under basal or IFNγ-stimulated conditions. Using pathway analysis, we show that MHC-II(+) cell lines demonstrate signatures of 'PD-1 signalling', 'allograft rejection' and 'T-cell receptor signalling', among others. In two independent cohorts of anti-PD-1-treated melanoma patients, MHC-II positivity on tumour cells is associated with therapeutic response, progression-free and overall survival, as well as CD4(+) and CD8(+) tumour infiltrate. MHC-II(+) tumours can be identified by melanoma-specific immunohistochemistry using commercially available antibodies for HLA-DR to improve anti-PD-1 patient selection.

Here...the tumor is being characterized by surface molecules that are correlated with prognosis:

Molecular markers to complement sentinel node status in predicting survival in patients with high risk locally invasive melanoma.  Rowe, Tang, Hughes, et al.  Int J Cancer. 2016 Mar 14. 

Sentinel lymph node status is a major prognostic marker in locally invasive cutaneous melanoma. However this procedure is not always feasible, requires advanced logistics, and carries rare but significant morbidity. Previous studies have linked markers of tumour biology to patient survival. In this study we aimed to combine the predictive value of established biomarkers in addition to clinical parameters as indicators of survival in addition to or instead of sentinel node biopsy in a cohort of high risk melanoma patients. Patients with locally invasive melanomas undergoing sentinel lymph node biopsy were ascertained and prospectively followed. Information on mortality was validated through the National Death Index. Immunohistochemistry was used to analyse proteins previously reported to be associated with melanoma survival, namely Ki67, p16, and CD163. Evaluation and multivariate analyses according to REMARK criteria were used to generate models to predict disease-free and melanoma-specific survival. 189 patients with available archival material of their primary tumour were analysed. Our study sample was representative of the entire cohort (N=559). Average Breslow thickness was 2.5 mm. 32 (17%) patients in the study sample died from melanoma during the follow-up period. A prognostic score was developed and was strongly predictive of survival, independent of sentinel node status. The score allowed classification of risk of melanoma death in sentinel node negative patients. Combining clinicopathological factors and established biomarkers allows prediction of outcome in locally invasive melanoma and might be implemented in addition to or in cases when sentinel node biopsy cannot be performed.

Here the tumor is being analyzed for specific genetic variations:   

Genomic and Transcriptomic Features of Response to Anti-PD-1 Therapy in Metastatic Melanoma.  Hugo, Zaretsky, Sun, et al.  Cell. 2016 Mar 15. 

PD-1 immune checkpoint blockade provides significant clinical benefits for melanoma patients. We analyzed the somatic mutanomes and transcriptomes of pretreatment melanoma biopsies to identify factors that may influence innate sensitivity or resistance to anti-PD-1 therapy. We find that overall high mutational loads associate with improved survival, and tumors from responding patients are enriched for mutations in the DNA repair gene BRCA2. Innately resistant tumors display a transcriptional signature (referred to as the IPRES, or innate anti-PD-1 resistance), indicating concurrent up-expression of genes involved in the regulation of mesenchymal transition, cell adhesion, extracellular matrix remodeling, angiogenesis, and wound healing. Notably, mitogen-activated protein kinase (MAPK)-targeted therapy (MAPK inhibitor) induces similar signatures in melanoma, suggesting that a non-genomic form of MAPK inhibitor resistance mediates cross-resistance to anti-PD-1 therapy. Validation of the IPRES in other independent tumor cohorts defines a transcriptomic subset across distinct types of advanced cancer. These findings suggest that attenuating the biological processes that underlie IPRES may improve anti-PD-1 response in melanoma and other cancer types.

While none of these (other than those that are simple measures of recognized blood components) are validated and ready for daily screening of cancer patients across this country....every step is important in helping docs...eventually....determine the best treatment options for the individual and monitor their response to that treatment in ways that are specific, easily measured, and less invasive and damaging to that patient.  What a beautiful day that will be!!!  Minimized only by the day we figure out how to avoid cancer entirely!  Hey....might as well live large and dream big!!! - c

Blood markers associated with clinical outcome of melanoma treated with ipi

Baseline peripheral blood biomarkers associated with clinical outcome of advanced melanoma patients treated with ipilimumab.  Martens, Wistuba-Hamprecht, Geukes Foppen, et al. Clin Cancer Res. 2016 Jan 19.

[This study was done as an attempt to] identify baseline peripheral blood biomarkers associated with clinical outcome following ipilimumab treatment in advanced melanoma patients. Frequencies of myeloid-derived suppressor cells (MDSCs) and regulatory T cells (Tregs), serum lactate dehydrogenase (LDH), routine blood counts, and clinical characteristics were assessed in 209 patients. Endpoints were overall survival (OS) and best overall response. Statistical calculations were done by Kaplan-Meier- and Cox-regression-analysis including calibration and discrimination by C-statistics. Low baseline LDH, absolute monocyte counts (AMC), Lin-CD14+HLA-DR-/low-MDSC frequencies, and high absolute eosinophil counts (AEC), relative lymphocyte counts (RLC), and CD4+CD25+FoxP3+-Treg frequencies were significantly associated with better survival, and were considered in a combination model. 43.5% of patients presenting with the best biomarker signature had a 30% response rate and median survival of 16 months. In contrast, patients with the worst biomarkers (27.5%) had only a 3% response rate and median survival of 4 months. The occurrence of adverse events correlated with neither baseline biomarker signatures nor the clinical benefit of ipilimumab. In another model, limited to the routine parameters LDH, AMC, AEC, and RLC, the number of favorable factors (4 vs. 3 vs. 2-0) was also associated with OS in the main study and additionally in an independent validation cohort. A baseline signature of low LDH, AMC and MDSCs as well as high AEC, Tregs and RLC is associated with favorable outcome following ipilimumab. Prospective investigation of the predictive impact of these markers following ipilimumab and other treatments, e.g. PD-1 antibodies, is warranted. So...common themes we have been seeing lately:  LOW LDH, AMC and MDSC's bode well for those treated with immunotherapy.  More related info here: LDH: LDH as predictor of outcome Being female with low LDH and no ulceration...good with BRAFi White cells: Neutrophils as prognostic predictor MDSC's: Markers for response to immunotherapy T-regs: How to make anti-PD1 work better Have a beautiful weekend! -c

Response after discontinuation of anti-PD-1 in melanoma patients whether due to disease progression, side effects or choice

The length of time melanoma patients should remain on immunotherapy and what happens to them after they come off has been a huge point of interest for researchers and patients since these drugs were first determined to be an effective treatment for melanoma.  In my Phase 1 nivolumab trial, begun in 2010, unless we progressed or developed untenable side effects, we were all allowed 2 1/2 years of therapy.  Period.  The end.  I was happy to be off it at the end.  However, that was certainly colored by the fact that I was NED.  Had I had lesions - stable or otherwise - I don't know that I would have been so at ease.  No matter, by the time I was reaching the end of my participation in 2013, Dr. Weber, lead investigator for the trial, was already postulating that we had been given the medication "too long".  His thinking ran along the lines that only a "certain amount" of the medication would do a patient any good and to give the medication longer would only increase the risk of side effects.  Still, determining the "certain amount" that does a body good has been hard to define.  In fact, I posted this in 2018:  Awesome news regarding how and when to stop immunotherapy in melanoma patients.  Now, seven years later, there is this...

When is it OK to Stop Anti-Programmed Death 1 Receptor (PD-1) Therapy in Metastatic Melanoma?  Banks and Sullivan.  Am J Clin Dermatol.  2020 Feb 5.

Systemic therapy for metastatic melanoma has been revolutionized over the past decade with the development of highly effective immune checkpoint inhibition, specifically anti-Programmed Death 1 receptor (PD-1) therapy. However, even though one-third of patients will have durable response to single-agent or combination therapy, the optimal duration of therapy is unknown. Identifying the optimal duration of therapy is important, as exposure to anti-PD-1 therapy increases the risk of developing immune-mediated toxicities that can have significant morbidity and are, at times, fatal. It has long been understood that patients with complete responses to high-dose interleukin-2 and ipilimumab typically maintain their responses after a brief treatment course; thus, it is important to better understand the data to help understand the optimal management of melanoma patients treated with anti-PD-1 therapy. The clinical data with anti-PD-1-based therapy and published data on the duration of therapy suggest that patients may not require a full 2 years of anti-PD-1 therapy and that the risk of toxicity may be mitigated by further understanding the mechanisms and kinetics of response to therapy. Although novel markers to help guide therapeutic decision making are under investigation, there is an ongoing need to improve our tools to monitor response to therapy and disease activity.

{Note:  Those "novel markers"  they mention refer to the various blood tests that allow us a peek into the body's response that melanoma peeps STILL aren't routinely allowed to avail ourselves of though researchers keep mentioning it and I keep YELLING about it!!!  As in the zillions of reports here on bio-markers generally:  Biomarkers  And these on circulating DNA in particular:  ctDNA }

Apart from not being very clear about how long melanoma patents really should continue immunotherapy for the best result, there is the issue of what happens to patients when they do stop.  Is the outcome different for those who must stop due to side effects as opposed to those who complete the current recommended doses?  Well...  I have reported this data over and over and over ~

This from 2016:  ASCO 2016 - Nivo plus ipi, CheckMate 069 trial....18 month OS similar even if you stop meds due to side effects!!!

And again in 2017:  40% of melanoma patients stop ipi/nivo due to side effects...BUT...efficacy is about the same!!!

Per this data, the difference made in response in those who "completed" the proposed therapy vs those who do not due to side effects is - NOT MUCH!!!!

I've also written posts that cover what happens to folks who choose to end their immunotherapy for whatever reason.  This link to a post in 2019 includes links to many others:  Anti-PD-1 results in melanoma patients: outcomes plus responses to retreatment

Now, there's this:

Discontinuation of anti-PD-1 antibody therapy in the absence of disease progression or treatment limiting toxicity: clinical outcomes in advanced melanoma.  Jansen, Rozeman, Mason, et al.  Ann Oncol.  2019 Jul 30.

Programmed cell death protein 1 (PD-1) blocking monoclonal antibodies improve the overall survival of patients with advanced melanoma but the optimal duration of treatment has not been established.  This academic real-world cohort study investigated the outcome of 185 advanced melanoma patients who electively discontinued anti-PD-1 therapy with pembrolizumab (N=167) or nivolumab (N=18) in the absence of disease progression (PD) or treatment limiting toxicity (TLT) at 14 medical centres across Europe and Australia.

Median time on treatment was 12 months (range 0.7-43). The best objective tumour response at the time of treatment discontinuation was complete response (CR) in 117 (63%) patients, partial response (PR) in 44 (24%) patients and stable disease (SD) in 16 (9%) patients; 8 (4%) patients had no evaluable disease (NE). After a median follow-up of 18 months (range 0.7-48) after treatment discontinuation, 78% of patients remained free of progression. Median time to progression was 12 months (range 2-23). PD was less frequent in patients with CR (14%) compared with patients with PR (32%) and SD (50%). Six out of 19 (32%) patients who were retreated with an anti-PD-1 at the time of PD obtained a new antitumour response.

In this real-world cohort of advanced melanoma patients discontinuing anti-PD-1 therapy in the absence of TLT or PD, the duration of anti-PD-1 therapy was shorter when compared with clinical trials. In patients obtaining a CR, and being treated for greater of equal to 6 months, the risk of relapse after treatment discontinuation was low. Patients achieving a PR or SD as best tumour response were at higher risk for progression after discontinuing therapy, and defining optimal treatment duration in such patients deserves further study. Retreatment with an anti-PD-1 at the time of progression may lead to renewed antitumour activity in some patients.

For what it's worth - again. ~ c

Eosinophilia - biomarker for prognosis in melanoma and importance in immunotherapy response

I've posted data about eosinophil counts as markers in melanoma before ~

Here in 2016:  Blood markers associated with clinical outcome of melanoma treated with ipi

Here in August of 2015:  Markers for response to immunotherapy: Increased eosinophils = good. Increased Myeloid Suppressor cells = not so good.

Here in June of 2015, with a graph of my own esosinophils while in my trial:  ASCO 2015: Eosinophilia with Nivo and Pembro - A predictor of success?!!

Eosinophilic count as a biomarker for prognosis of melanoma patients and its importance in the response to immunotherapy. Moreira, Lesigana, Schuler, Heinzerling. Immunotherapy. 2017 Jan.

The prognostic role of eosinophils in cancer has been controversial. Some entities such as gastrointestinal cancers show a better survival, while others such as Hodgkin's lymphoma a worse survival in patients with eosinophilia. Patients who exhibited an increase in eosinophils upon therapy with ipilimumab or pembrolizumab were shown to survive longer. We wanted to investigate whether eosinophilia is a prognostic marker in metastatic melanoma.

In total, 173 patients with metastatic melanoma from our data base (median age 60 years; n = 86 with immunotherapy, n = 87 without immunotherapy) were analyzed for eosinophil counts and survival over the course of 12 years. Eosinophilic count was detected by peripheral blood smear. The ethical committee had approved this retrospective study.

Melanoma patients with eosinophilia at any point in their course of disease show a trend toward longer survival independently of their therapy. There is a statistically significant difference for the patients who survive at least 12 months. In patients with checkpoint inhibitor therapy, survival was significantly prolonged in every patient with eosinophilia. Furthermore, 69% of the patients treated with immunotherapy experienced at least once an eosinophilia of 5% or greater compared with 46% in the immunotherapy naive-group; for an eosinophilia of 10% values were 30 and 9%, respectively. Interestingly, in patients with more than 20% eosinophils (n = 7) survival was prolonged with a median of 35 months (range 19-60 months) as compared with 16 months (range 1-117 months).


Eosinophilia is a prognostic marker in patients with metastatic melanoma.

It is looking more and more as though increased esosinophils indicate an improved prognosis for melanoma patients.  Hopefully, this finding will soon materialize in a methodology for making better treatment choices or to attain eosinophilia (if that is what we need to do) in order to create better outcomes....rather than just interesting incidental data.  Clearly, there is much we do not understand when it comes to our immune systems!! - c

Melanoma antigens in blood are prognostic of OS and correlated with response to ipi!

I've talked about biomarkers before.  Here's a post from earlier this year (with additional links within - including one to another study that found blood biomarkers associated with response to ipi):  Biomarkers - blood components, circulating tumor cells AND of the tumor itself 

A valid and specific blood draw that could help diagnose, determine the presence of a response to therapy, and be used as follow-up (instead of scans!) would be sooooooooooo  awesome!!!!  Now there's this:

Melanoma antigens are biomarkers for ipilimumab response.  Arenberger, Fialova, Gkalpakiotis, et al.  J Eur Acad Dermatol Venereol. 2016 Aug 24. 

Novel immunotherapy modalities significantly improve survival of patients with metastatic melanoma. However, CTLA-4-blocking monoclonal antibody ipilimumab is effective only in a small proportion of patients. Biomarkers for prediction of treatment response are indispensably needed.

To determine the utility of multimarker detection of circulating melanoma cells as prognostic and pharmacodynamic biomarker in patients with metastatic melanoma treated with ipilimumab.

Patients (n=62) with metastatic melanoma in unresectable stage III or metastatic stage IV treated with ipilimumab were recruited prospectively. The values of 4 melanoma markers on circulating cells Melan-A, gp100, MAGE-3 and MIA prior to the treatment and within the therapy were compared to the data collected at baseline - after the melanoma surgery.

The immunotherapy pretreatment marker level was found to be prognostic of overall survival, lower levels were linked to longer survival time. Moreover, longitudinal follow-up of melanoma markers in patients treated with ipilimumab correlates with therapy response. A decline of marker levels by greater than 30% at week 6 (in 83% of the responding subjects) to week 9 (in all responders) of ipilimumab administration was associated with response to therapy. Elevation of the tumor markers during the treatment precedes clinical progression and gives an early warning of treatment failure. 

Melanoma circulating cells hold potential as predictive and pharmacodynamic biomarker of immunotherapy.

Come on researchers.  Let's make this happen!  Soon!!! - c

Markers for response to immunotherapy: Increased eosinophils = good. Increased Myeloid Suppressor cells = not so good.

Myeloid Cells and related chronic inflammatory factors as novel predictive markers in melanoma treatment with ipilimumab.  Gebhardt, Sevko, Jiang, et al.  Clin Cancer Res. 2015 Aug 19.

Ipi improves survival of patients with metastatic melanoma.  Since only about 20% of patients experience long-term benefit, reliable markers are needed to predict response.  Analysis of blood of 59 Stage IV melanoma patients was analyzed before treatments and at different times during treatment.  An early increase in eosinophil count during treatment with ipi was associated with an improved clinical response. In contrast, elevated numbers of monocytic myeloid-derived suppressor cells (moMDSCs), neutrophils, and monocytes were found in non-responders (n=36) as compared to levels in responding patients (n=23).  Non-responders also produced more nitric oxide and granulocytic MDSCs expressed higher levels of PD-L1 ... suggesting their enhanced immunosuppressive capacity.  Upon the first ipi infusion, non-responders displayed high serum concentrations of S100A8/A9 and HMGB1 that attract and activate MDSCs.

So....folks with increased eosinophils do better.  Folks with increased numbers of myeloid-derived suppressor cells, neutrophils, and monocytes do not.  Here is more data to support the same findings:

Lab values that may predict response to Ipi

Eosinophilia and a positive response to nivo and pembro

In this link Weber talks ipi and combo's, several immunotherapy combo's are discussed...but the relevant part addresses the blood work from the folks taking nivo in my study:
 

Looking at pretreatment parameters in the periphery and the tumor-
Only baseline MDSC, myeloid derived suppressor cells, proved to be significant.
These are CD14, HLA-DR low, CD11 B+ cells, classic myeloid derived suppressor cells which express high levels of PDL1 and other check point proteins.
Neutrophil derived MDSC cells were not related.
The more myeloid suppressor cells you have, the worse the patient did both in response rate and survival. 
Weber hopes to soon have results of the levels of MDSC from within the tumors of these patients and see how that level related to outcomes.
You can block MDSC by incubating it with PD1 antibody as well as other check point proteins, so he is writing a grant proposal currently to test a combo of nivo with MDSC depletion.
Measurements of the T-regs in the periphery - Levels decreased in responders, in non-responders it went up. For this reason, also thinks that nivo with T-reg depletion is worth investigation.


Here, in a synopsis of articles about the positive effects of combining immunotherapy and radiation, Radiation for melanoma, better when combined with immunotheapy!, once again....patients do better when MDSCs are few and far between:  Concomitant with tumor regression from radiation, they noted that radiation and anti-PD-L1 worked together to reduce the local accumulation of tumor-inflitrating myeloid-derived suppressor cells (MDSCs)... {Note:  Remember, these are the bad guys that block your T cells.  In my study, the folks with high levels of MDSCs did least well, while those with the lowest levels did better.  That's why, some researchers, like Weber, are talking about depleting these cells in patients FIRST...then administering anti-PD1 or other immunotherapies!!}  So...the data acquired in this study demonstrated evidence of the interaction between radiation and T cells....and a basis for the rational design of combination therapy with immune modulators and radiotherapy.

Really thinking the idea about depleting MDSCs at the start may really be the way to go here!!!  Best - c 

ASCO 2016 - Measuring T-cell exhaution to predict response to anti-PD1 vs ipi/nivo combo....plus...ALC increases and delayed increases in CD4+ and CD8+ T cells = positive outcomes with ipi

Finding a marker...of any sort....than can be tested easily and evaluated consistently...to predict response to therapy would be an amazing leap forward in melanoma treatment.  I have looked at what researchers are exploring before here:  Biomarkers: blood components, circulating tumor cells and the tumor itself  

Now there is this:

Novel T cell exhaustion marker to predict monotherapy PD-1 compared to combination CTLA-4 and PD-1 response in melanoma.  ASCO 2016.  #9520.  J Clin Oncol 34, 2016.  Loo, Tsai, Pauli, et al.

Background: The identification of a robust biomarker to determine potential responses to checkpoint mono- or combination therapy is critical in order to stratify patients and rationally select therapy. We explored the utility of proportion “exhausted” antigen experienced T cells (TEx)/Total CD8+ cells to predict response. Methods: Freshly isolated tumor samples were digested and tumor infiltrating lymphocytes (TILs) were extracted and stained with T cell myeloid and activation markers, and analyzed with 14 color FACS. Patients were treated with the combination therapy Ipilimumab 3 mg/kg q3 week x 4 and Nivolumab 1 mg/kg q3 week (Ipi/Nivo), or monotherapy of either Nivolumab 3 mg/kg q2 week or Pembrolizumab 2 mg/kg q3 week. TEx was calculated as % CD8+, PD-1+, CTLA-4+ cells divided by total CD8+ T cells in the tumor sample. Results: A total of 53 patients were evaluable for both response and T cell phenotype, 15 patients were treated with combination Ipi/Nivo, and 38 with monotherapy PD-1. For monotherapy, 0/12 (0%) responders had a TEx less than/= to, 20%, while 21/26 (81%) of the responders had a TEx greater than 20%. For responders, median TEx = 40.3%, for non-responders, median TEx = 16%,. At this threshold, the negative predictive value (NPV) was 100% and the positive predictive value (PPV) was 81%. For patients treated with combination Ipi/Nivo, the threshold for response was much lower. Responses to the combination therapy were seen at all levels with NPV=50% and PPV=80%, with responders median TEx = 19.7% and non-responders median TEx = 7.8%. Conclusions: Comprehensive tumor T cell profiling with FACS reveals interesting insights into tumor response to checkpoint inhibitors. % TEx is an accurate predictor of response to monotherapy but not combination checkpoint therapy. Combination Ipi/Nivo therapy produces responses at a much lower TEx threshold, suggesting enhanced rescue and/or recruitment of T cells into the tumor microenvironment. 

% TEx	Monotherapy PD-1, ORR	NPV %	PPV %
> 20%	81%	100	81
≤20%	0%
	Ipi/Nivo, ORR	50	80
>20%	80%
≤20%	50%

Believe it or not...this bunch of mess makes common sense.  If a group of people with melanoma have very exhausted t cells...that means that those cells have been fighting the beast, but have become worn out doing so.  Giving them a treatment that boosts t cell action...like anti-PD1...will more likely be effective for them rather than for those whose t cells were still active and NOT tired...just not effective against their melanoma.  However, this was true only for the administration of anti-PD1 monotherapy, the difference was not as striking when patients were given the ipi/nivo combo...probably due to the fact that ipi works much earlier in the immune response cycle by helping recruit the initial response. So....this could be helpful in deciding which patients would glean the most benefit from the combo, despite its potential side effects, as opposed to those who would be benefited by anti-PD1 alone. Look at the graph above.  When greater than 20% of your t cells are worn out, you get an 80% of a chance of a response to anti-PD1 alone...which is the same for the t cell exhausted folks who took the combo.  BUT!  If your cells were NOT exhausted, you have a 0% chance of response to anti-PD1 alone, but a 50% chance of response to the ipi/nivo combo.


This next study follows other work done to determine what peripheral blood markers are associated with what outcomes in patients who have taken ipilimumab...some of the work by some of the same peeps with links to other info is here:  Blood markers associated with clinical outcomes with ipi

Increases in absolute lymphocytes and circulating CD4+ and CD8+ T cells are associated with positive clinical outcome of melanoma patients treated with ipilimumab.  Martens, Wistuba-Hamprecht, Yuan,...Wolchok, et al.  Clin Cancer Res. 2016 May 11.

[This study was done] to investigate changes of peripheral blood biomarkers and their impact on clinical outcome following treatment with ipilimumab in advanced melanoma patients.

Changes in blood counts and the frequency of circulating immune cell populations analyzed by flow cytometry were investigated in 82 patients to compare baseline values with different time-points after starting ipilimumab. Endpoints were overall survival (OS) and best clinical response. Statistical calculations were done....

Increases in absolute lymphocyte counts (ALC) 2-8 weeks and in percentages of CD4+ and CD8+ T cells 8-14 weeks  after the first dose of ipilimumab were correlated with improved survival. These associations did not meet significance criteria, when conservatively adjusted for multiple testing but were additionally correlated with clinical responses. However validation is required. Increases in all three factors were observed in 36% of patients, who had a favorable outcome and survival probabilities of 93.3% and 63.8% at 12 and 24 months, respectively. A partial or complete response was observed in 71% of these patients compared to only 8% in patients with decreases in {greater than or equal to}1 of the 3 factors, respectively. Changes of regulatory T cells (Tregs) or myeloid-derived suppressor cells (MDSCs) were not associated with OS.

Increases of ALC observed 2-8 weeks after initiation of ipilimumab and delayed increases in CD4+ and CD8+ T cells reflect changes associated with positive outcome. These changes represent surrogate marker candidates and warrant further validation.

This is only applicable to ipi, but is a more readily available blood test than the evaluation noted in the prior study.

My brain is tired.  Thanks for your brain power, B!! Best - c

Research that makes you scratch your head - brain power to kill cancer and sleep disordered breathing, relative to melanoma outcomes??? Ummmm, okay.

I don't know how to introduce these reports any better than as "head scratchers"!!!  Here we go!

Modulation of anti-tumor immunity by the brain's reward system.  Ben-Shaanan, Schiller, Azulay, et al.  Nat Commun. 2018 Jul 13.

Regulating immunity is a leading target for cancer therapy. Here, we show that the anti-tumor immune response can be modulated by the brain's reward system, a key circuitry in emotional processes. Activation of the reward system in tumor-bearing mice (Lewis lung carcinoma (LLC) and B16 melanoma) using chemogenetics (DREADDs), resulted in reduced tumor weight. This effect was mediated via the sympathetic nervous system (SNS), manifested by an attenuated noradrenergic input to a major immunological site, the bone marrow. Myeloid derived suppressor cells (MDSCs), which develop in the bone marrow, became less immunosuppressive following reward system activation. By depleting or adoptively transferring the MDSCs, we demonstrated that these cells are both necessary and sufficient to mediate reward system effects on tumor growth. Given the central role of the reward system in positive emotions, these findings introduce a physiological mechanism whereby the patient's psychological state can impact anti-tumor immunity and cancer progression.

Hmm... Okay...
1.  We have known for years that fewer MDSC's is a positive sign when dealing with melanoma.  Here's a bunch of posts and data on myeloid derived suppressor cells (MDSCs) and their role in melanoma .  In fact, I noted this in 2014 in regard to outcomes in my trial:

"MDSC  (myeloid derived suppressor cells)
"There was a trend towards lower baseline MDSC levels in non-relapsing patients compared to relapsing patients."  This bit of stuff and such along with other Treg/Tcell data comes your way thanks to us ratties sitting through leukapheresis twice during the trial. However, this is a bit I'm pretty psyched about.  There is talk among melanoma big dogs that combining anti-PD1 with MDSC or T-reg depletion would make it more effective.  I think that holds real promise.  Though...once again...despite my blood and services having been rendered....I have no idea what my MDSC levels were.  Still...I think this could be a real boon to future patients."

2.  In the entire article, linked here if you choose to read it ~  Modulation..., the authors note: 

"Epidemiological evidence supports a connection between the patient’s mental state and cancer survival, Nevertheless, many of these studies have yielded inconsistent results, and our understanding of the central neuronal mechanisms underlying the effect of emotional states on cancer is limited. Moreover, most research in this field has been focused on negative emotional states, such as stress and depression, while the impact of positive mental attributes on cancer biology is largely unknown."  

Don't get me wrong, I believe in "HAPPY"!!!  We all feel better and do better when all is right in our world!  Duh!!!  However, keeping your ass happy when dealing with the reality of a deadly disease, the pain and cost of treatment, the pain and emotional cost to loved ones, the economic and personal value lost due to unemployment when you are too sick to work... I could go on!  Melanoma is NOT easy.  Putting on a happy face, no matter how real (or not) it may be, will not cure your melanoma nor protect you from it!!!  Here's some real data and a bit of a rant:  ASCO 2017: Friends in need are friends indeed! Here's to the caregivers!!!

3.  But, I digress.  In this study, researchers gave real live little ratties either a type of lung cancer or melanoma.  And because we already know that part of our immune system serves us well in fighting cancer (our CD8 t cells and natural killer [NK] cells for instance) while other parts (like the MDSCs) actually SUPPRESS anti-tumor responses and let tumors thrive...the researchers note:  "...by depleting and adoptively transferring MDSCs, we showed that these cells are both necessary and sufficient to mediate the effects of reward system activation on tumor growth."  In order to test that, very roughly, they made a happy drug ("...we used Designer Receptor Exclusively Activated by Designer Drugs (DREADDs) to specifically control reward system activity...") which they got into these poor little ratties heads {for realz!!!} by attaching it to a cold virus and zapping it into their brains with SRS.  Damn!  It sucks to be a rattie!!!  For the control, they did all the same stuff, just minus the happy pill.  So, according to these researchers, this process allowed the zapped with the happy pill ratties' dopaminergic neurons to get busy with their secretions and stimulations - ultimately impacting the bone marrow, which impacted the MDSC's, making them LESS immunosuppressive.  There.  By the way, the effect was less in the melanoma injected ratties than it was for the lung cancer ratties....so the researchers actually abandoned the melanoma critters mid-way the study and just used the lung cancer critters.

4.  All in all, this is probably much ado about nothing as it relates to us human melanoma ratties.  EXCEPT!!!  As I said above and in 2014:  "There is talk among melanoma big dogs that combining anti-PD1 with MDSC or T-reg depletion would make it more effective.  I think that holds real promise.  Though...once again...despite my blood and services having been rendered....I have no idea what my MDSC levels were.  Still...I think this could be a real boon to future patients."   So, if this is part of the process to get us there - so be it!!

Now, this...

Sleep-disordered breathing is independently associated with increased aggressiveness of cutaneous melanoma.  A multicentre observational study in 443 patients.  Martinez-Garcia, Campos-Rodriguez, Nagore, et al.  Chest.  2018 Jul 27.

Sleep-disordered breathing (SDB) has been associated with a greater incidence and mortality of cancer, although such findings are inconsistent. However, no large studies are currently available to investigate this association in patients with a specific type of cancer. This study seeks to assess potential relationships between SDB severity and aggressiveness markers of cutaneous melanoma.

443 patients with a diagnosis of melanoma underwent a sleep study within 6 months of diagnosis. General demographics were collected, along with melanoma characteristics and polygraphic parameters consisting of apnea-hypopnea index (AHI) and indices of both continuous and intermittent night-time oxyhemoglobin desaturation (DI4%). Exploration of independent relationships between SDB and various objective melanoma aggressiveness markers (Breslow index, presence of ulceration, presence of regression, mitotic index, stage of severity, damage to the sentinel lymph and spreading of the melanoma) was performed.

Patients in the upper tertiles of AHI or DI4% were 1.94 and 1.93 times more likely, respectively, to present with aggressive melanoma (Breslow index greater than 1mm) than those in the lowest tertiles of these sleep attributes after adjustment for age, gender, tumor location and body mass index. This association was particularly prominent among patients less than 56 years with Breslow index greater than 2 mm. The presence of the additional markers of aggressiveness was also associated with higher AHI and DI4% values.  The severity of the SDB was independently associated with greater aggressiveness of cutaneous melanoma, particularly among younger patients.

Hmmmm.....well.  
1.  Maybe folks who are more worried about their melanoma sleep less well!!!  And sleeping less well about having a potentially deadly disease is completely legit!!!  
2.  Then again, maybe these particular melanoma peeps are less happy about their life and therefore invite melanoma in, like the sad rats in the previous study???  (Y'all know that is NOT what I think!!  Right????)  
3.  Maybe younger folks with melanoma lesions of greater than 2 mm in depth were at greater risk anyway!!!!  Cause that's a thing!!!!  With melanoma: You can never be too rich or too thin! But, you can be too young!!!
4.  Finally, no matter what you think of this report (and I don't think much!!!!) ain't no way insurance is going to pay for sleep studies just because you've been diagnosed with melanoma.  It's hard enough to get them to pay for scans we actually need!!!

Head gett'n itchy yet???  Sometimes we have to think, laugh, yawn, and plain out hope researchers are getting SOMEWHERE that will actually make a difference where we need it!!! Hang tough, ratties!!  c

HDAC6 as a way to decrease immunosuppression in melanoma patients...

Researchers have been looking at, and I've reported on their research, regarding HDAC inhibitors for some time.  Initially, they were considered as something that could be added to targeted therapy in order to prevent, delay, or overcome resistance to BRAF inhibitors.  It has also been postulated that combining HDAC inhibitors with immunotherapy could increase the effectiveness of that therapy by making melanoma cells more sensitive to it.  Entinostat and Ricolinostat are two such HDAC inhibitors.

Now there's this:

HDAC6 selective inhibition of melanoma patient T-cells augments anti-tumor characteristics.  Laino, Betts, Veerapathran…Weber, et al. J Immunother Cancer. 2019 Feb 6.

Therapies targeting anti-tumor T-cell responses have proven successful in the treatment of a variety of malignancies. However, as most patients still fail to respond, approaches to augment immunotherapeutic efficacy are needed. Here, we investigated the ability of histone deacetylase 6 (HDAC6)-selective inhibitors to decrease immunosuppression and enhance immune function of melanoma patient T-cells in ex vivo cultures.  T-cells were harvested from peripheral blood or tumor biopsies of metastatic melanoma patients and cultured in the presence of pan-, class-specific or class-selective histone deacetylase (HDAC) inhibitors. Changes in cytokine production were evaluated by Luminex and intracellular flow cytometry staining. Expression of surface markers, transcription factors, protein phosphorylation, and cell viability were assessed by flow cytometry. Changes in chromatin structure were determined by ATAC-seq.

T-cell viability was impaired with low doses of pan-HDAC inhibitors but not with specific or selective HDAC inhibitors. The HDAC6-selective inhibitors ACY-1215 (ricolinostat) and ACY-241 (citarinostat) decreased Th2 cytokine production (i.e. IL-4, IL-5, IL-6, IL-10 and IL-13). Expansion of peripheral blood T-cells from melanoma patients in the presence of these inhibitors resulted in downregulation of the Th2 transcription factor GATA3, upregulation of the Th1 transcription factor T-BET, accumulation of central memory phenotype T-cells (CD45RA-CD45RO + CD62L + CCR7+), reduced exhaustion-associated phenotypes (i.e. TIM3 + LAG3 + PD1+ and EOMES+PD1+), and enhanced killing in mixed lymphocyte reactions. The frequency, FOXP3 expression, and suppressive function of T regulatory cells (Tregs) were decreased after exposure to ACY-1215 or ACY-241. Higher frequencies of T-cells expressing CD107a + IFNγ+ and central memory markers were observed in melanoma tumor-infiltrating lymphocytes (TIL), which persisted after drug removal and further expansion. After ACY-1215 treatment, increased chromatin accessibility was observed in regions associated with T-cell effector function and memory phenotypes, while condensed chromatin was found in regions encoding the mTOR downstream molecules AKT, SGK1 and S6K. Decreased phosphorylation of these proteins was observed in ACY-1215 and ACY-241-treated T-cells. AKT- and SGK1-specific inhibition recapitulated the increase in central memory frequency and decrease in IL-4 production, respectively, similar to the observed effects of HDAC6-selective inhibition.

HDAC6-selective inhibitors augmented melanoma patient T-cell immune properties, providing a rationale for translational investigation assessing their potential clinical efficacy.

Step by step!  Hopefully these inhibitors will benefit real live melanoma ratties very soon!!!  - c

Prognostic markers in Stage IIIC melanoma

Not really news....but.....

Clinical prognostic markers in stage IIIC melanoma.  Madu, Schopman, Berger, et al.J Surg Oncol. 2017 Apr 15. 

Although the EORTC 18071-trial has shown a clear survival benefit for adjuvant ipilimumab, accurately selecting patients for this toxic adjuvant therapy is important. We aimed to identify prognostic factors for death and disease recurrence in AJCC stage IIIC melanoma patients.

Retrospective analysis of patients who underwent lymph node dissection (LND) for stage IIIC melanoma in our institution between 2000 and 2016. Baseline characteristics, melanoma-specific survival (MSS), and disease-free survival (DFS) were assessed, and prognostic factors for recurrence and survival were analyzed using uni- and multivariable analysis.
A total of 205 patients were included. Median follow-up was 20 months (interquartile range 11-43 months), median MSS was 28 months, and median DFS was 11 months. Five-year MSS was 33% and 5-year DFS was 23%. N3 (greater or = to 4 involved lymph nodes) and extracapsular extension (ECE) carried an increased risk of disease recurrence after LND and death by melanoma. Patients with both N3 and ECE had virtually no long-term survival.

Although survival for patients with stage IIIC is poor in general, patients with both N3 disease and ECE constitute the group with the worst prognosis and should be considered for adjuvant therapy with ipilimumab or any other future effective adjuvant therapy (study).

So....we already knew that folks with more positive nodes and melanoma extended beyond the nodes were certainly more vulnerable to progression.

However, we also know this:  Prolonged survival in Stage III melanoma treated with ipi as adjuvant!!!

Yet, when faced with this conundrum - this data would give me pause:  Sequential nivo then ipi = ORR of 41%. Ipi followed by nivo = ORR of 20%!!!! 

Hang in there ratties.  It pays to have long tails.  Wishing you all my best. - c

Another look at a recent study of proteins in our blood that predict response to anti-PD-1!!!

A couple of days ago I posted this:  A simple blood draw to measure serum protein - predicts outcome for melanoma patients treated with anti-PD-1????

It is a review of the article you can find here and peruse yourself:  A Serum Protein Signature Associated with Outcome After Anti-PD1 Therapy in Metastatic Melanoma Jeffrey S. Weber, Mario Sznol, Ryan J. Sullivan, Shauna Blackmon, Genevieve Boland, Harriet M Kluger, Ruth Halaban, Antonella Bacchiocchi, Paolo A Ascierto, Marilena Capone, Carlos Oliveira, Krista Meyer, Julia Grigorieva, Senait G Asmellash, Joanna Roder and Heinrich Roder Cancer Immunol Res December 8 2017

Some of my peeps had a few more questions, and I found the whole shmegegge super interesting, (Especially when you think about it in light of all the other potential that a simple blood analysis has regarding tumor burden and other biomarkers:  Measuring cell-free DNA in melanoma patient's blood to determine tumor burden and prognosis!) so here is a more thoughtful analysis than my first.....

After a thorough review of the entire article, along with all the tables and figures with my trusty B....here's what we got:

Dr. Weber made an earlier presentation of some of this data at a conference in 2015...so it's been cooking a while.

The main gist is pretty straight forward: Researchers used pooled data from multiple institutions and several studies of ratties (n = 289) who took nivo, pembro, ipi, or the ipi/nivo combo (along with those of us who took nivo with peptide vaccines). Some of the ratties had already had ipi, before taking anti-PD-1 and some had not. Blood was drawn before the ratties started treatment. Those samples were analyzed using advanced techniques to tease out what proteins in the blood were present in the sensitive set (patients who responded) vs the resistant set (patients who did not). After that first examination was completed, researchers used the same protein markers on test sets. The protein markers were successful in distinguishing those likely to be sensitive (responders) from those who were likely to be resistant (non-responders). In addition, they analyzed the proteins to identify the mechanisms of sensitivity or resistance. There they found proteins associated with: 

1. wound healing

2. active phase reactants (the body's inflammatory response)

3. complement activation (another immune mechanism we use to respond to abnormal molecules – which could be anything from worms to cancer).

This test clearly worked to predict response for folks taking anti-PD-1 alone or taking ipi alone. However, when ipi/nivo was taken together the proteins were not predictive of response. (As an aside if you look at the graphs...Sets 2 and 3 are not currently significant, probably because the length of time passed at review of data was not adequate.)  You can take a look at the graphs in the link above or my pic below.

Researchers repeatedly note that application of this test to a larger group is needed to validate and further refine these results. Still – I am hopeful that knowledge of these proteins will provide guidance for future therapeutic interventions. For instance, if we could enhance wound healing while simultaneously decreasing inflammatory response and complement activation, we might be able to make anti-PD-1 therapy more effective. However, the current test as is - cause remember, these samples were taken BEFORE any of these ratties got any anti-PD-1 therapy - could refine prediction of who would benefit from current anti-PD-1 treatment and who may not.  For instance, if your blood samples showed proteins indicating that you were likely to respond to anti-PD-1 alone, especially if we were to examine that same blood draw for circulating tumor DNA and other biomarkers, it may help your decision making process when considering anti-PD-1 therapy vs the ipi/nivo combo with its increased rate of potential side effects.

Come on, researchers.  Let's get these tests out there!!!  Here's to the ratties! love, c