Immunogenomic predictors of outcomes in patients with locally advanced cervical cancer treated with immunotherapy and chemoradiation

项目概要/摘要 与人乳头瘤病毒（HPV）感染相关的局部晚期宫颈癌（LACC）持续存在， 是美国和全球发病率和死亡率的重要来源。尤其是有证据表明 的淋巴结转移患者的3年总生存率为39%， 目前的标准治疗化疗联合放疗（CRT）。因此，迫切需要 为高危LACC患者开发新的治疗策略。CRT与 靶向PD-L1（durvalumab）或PD-1（pembrolizumab）的免疫检查点阻断（ICB）药物正在 分别在全球前瞻性试验CALLA和KEYNOTE A18中进行了研究。不幸的是， CALLA试验未能证明添加durvalumab后24个月生存率的实质性改善， 强调LACC中CRT和ICB组合的几个关键知识差距。第一，最优排序 CRT和ICB的并发症是未知的，并且有明确的担忧，即CRT和ICB的同时启动会导致 杀伤肿瘤和肿瘤引流淋巴结中活化增殖T细胞的潜力，导致耐受。 其次，ICB和CRT治疗患者的长期结局预测因素尚不清楚。在这 应用，我们的主要研究目标是检查血液和肿瘤的演变 微环境（TME）免疫参数响应差异ICB-CRT测序和 建立长期结果的预测指标。为了实现这些目标，我们进行并完成了一项 NCI申办的PD-L1抑制剂atezolizumab联合CRT治疗高危患者的临床试验 LACC，将患者随机分配至在CRT之前和同时接受atezolizumab给药vs.同时 CRT治疗36例。该研究包括全面收集治疗前和治疗中的肿瘤 活组织检查、血液和PET扫描，这将使我们能够解决上述知识差距。在目标1中， 确定肿瘤免疫微环境如何作为差异免疫治疗的函数演变， CRT序列。通过使用多参数荧光显微镜，我们将确定如何激活T 细胞及其与肿瘤中其他细胞的相互作用对治疗的反应发生变化， 预测长期结果。在目标2中，我们将利用T细胞受体（TCR）库测序， 以及先进的生物信息学技术来评估肿瘤和外周血中T细胞的进化 可以作为抗肿瘤免疫反应和长期结果的指标。在目标3中，我们将建立 影像学和血液生物标志物作为高风险LACC患者预后的预测因子 HPV DNA和治疗后PET-CT作为治疗前和治疗后疾病负担的标志物。鉴定 预测预后的早期生物标志物对于LACC患者的风险分层至关重要， 为了指导临床试验或维持治疗的患者选择，同时最大限度地减少 潜在的临床毒性和经济负担的患者在低风险的复发。

Project Summary/Abstract Locally advanced cervical cancer (LACC) associated with human papillomavirus (HPV) infection continues to be a significant source of morbidity and mortality in the US and globally. In particular, patients with evidence of metastases to lymph nodes have a dismal 3-year overall survival of 39%, despite treatment with the current standard of care of chemotherapy combined with radiation (CRT). There is thus a critical need to develop new therapeutic strategies for patients with high-risk LACC. Combinations of CRT with immune checkpoint blockade (ICB) drugs targeting PD-L1 (durvalumab) or PD-1 (pembrolizumab) are being studied in global prospective trials CALLA and KEYNOTE A18, respectively. Unfortunately, the results of the CALLA trial failed to demonstrate substantial improvement in 24-month survival with addition of durvalumab, highlighting several critical knowledge gaps in combination of CRT and ICB in LACC. First, optimal sequencing of CRT and ICB is unknown, and there are clear concerns that concurrent initiation of CRT and ICB carries a potential to kill activated proliferating T cells in tumors and tumor-draining lymph nodes, leading to tolerance. Second, predictors of long-term outcomes for the patients treated with ICB and CRT are unknown. In this application, our key study objectives are to examine the evolution of blood and tumor microenvironment (TME) immune parameters in response to differential ICB-CRT sequencing and to establish the predictors of long-term outcomes. To achieve these goals, we conducted and completed an NCI-sponsored clinical trial of PD-L1 inhibitor atezolizumab in combination with CRT in patients with high-risk LACC, randomizing patients to atezolizumab administration prior to and concurrent with CRT vs. concurrent with CRT in 36 patients. The study incorporated comprehensive collection of pre- and on-treatment tumor biopsies and blood and PET scans that will enable us to address the knowledge gaps above. In Aim 1 we will determine how the tumor immune microenvironment evolves as a function of differential immunotherapy and CRT sequencing. By using multi-parameter fluorescence microscopy, we will determine how activation of T cells and their interaction with other cells in the tumors change in response to therapy and how these changes predict long term outcomes. In Aim 2, we will take advantage of T cell receptor (TCR) repertoire sequencing as well as advanced bioinformatics techniques to evaluate how evolution of T cells in tumors and peripheral blood could serve as an indicator of anti-tumor immune response and long-term outcomes. In Aim 3 we will establish radiographic and blood biomarkers as predictors of outcomes in high-risk LACC patients by examining blood HPV DNA and post-treatment PET-CT as markers of disease burden pre- and post-therapy. Identification of early biomarkers predictive of outcomes will be critical for risk-stratification of patients with LACC in order to guide patient selection for clinical trials or maintenance therapy, while minimizing the potential clinical toxicities and financial burden in patients at low risk for recurrence.