Immunoscore immune checkpoint using spatial quantitative analysis of CD8 and PD-L1 markers is predictive of the efficacy of anti- PD1/PD-L1 immunotherapy in non-small cell lung cancer.

BACKGROUND: Anti-PD-1 and PD-L1 antibodies (mAbs) are approved immunotherapy agents to treat metastatic non-small cell lung cancer (NSCLC) patients. Only a minority of patients responds to these treatments and biomarkers predicting response are currently lacking. METHODS: Immunoscore-Immune-Checkpoint (Immunoscore-IC), an in vitro diagnostic test, was used on 471 routine single FFPE-slides, and the duplex-immunohistochemistry CD8 and PD-L1 staining was quantified using digital-pathology. Analytical validation was performed on two independent cohorts of 206 NSCLC patients. Quantitative parameters related to cell location, number, proximity and clustering were analysed. The Immunoscore-IC was applied on a first cohort of metastatic NSCLC patients (n = 133), treated with anti-PD1 or anti-PD-L1 mAbs. Another independent cohort (n = 132) served as validation. FINDINGS: Anti-PDL1 clone (HDX3) has similar characteristics as anti-PD-L1 clones (22C3, SP263). Densities of PD-L1+ cells, CD8+ cells and distances between CD8+ and PD-L1+ cells were quantified and the Immunoscore-IC classification was computed. Using univariate Cox model, 5 histological dichotomised variables (CD8 free of PD-L1+ cells, CD8 clusters, CD8 cells in proximity of PD-L1 cells, CD8 density and PD-L1 cells in proximity of CD8 cells) were significantly associated with Progression-Free Survival (PFS) (all P < 0.0001). Immunoscore-IC classification improved the discriminating power of prognostic model, which included clinical variables and pathologist PD-L1 assessment. In two categories, the Immunoscore-IC risk-score was significantly associated with patients' PFS (HR = 0.39, 95% CI (0.26-0.59), P < 0.0001) and Overall Survival (OS) (HR = 0.42, 95% CI (0.27-0.65), P < 0.0001) in the training-set. Further increased hazard ratios (HR) were found when stratifying patients into three-category Immunoscore-IC (IS-IC). All patients with Low-IS-IC progressed in less than 18 months, whereas PFS at 36 months were 34% and 33% of High-IS-IC patients in the training and validation sets, respectively. INTERPRETATION: Immunoscore-IC is a powerful tool to predict the efficacy of immune-checkpoint inhibitors (ICIs) in patients with NSCLC. FUNDING: Veracyte, INSERM, Labex Immuno-Oncology, Transcan ERAnet European project, ARC, SIRIC, CARPEM, Ligue Contre le Cancer, ANR, QNRF, INCa France, Louis Jeantet Prize Foundation.

Establishment of a pancreatic adenocarcinoma molecular gradient (PAMG) that predicts the clinical outcome of pancreatic cancer.

BACKGROUND: A significant gap in pancreatic ductal adenocarcinoma (PDAC) patient's care is the lack of molecular parameters characterizing tumours and allowing a personalized treatment. METHODS: Patient-derived xenografts (PDX) were obtained from 76 consecutive PDAC and classified according to their histology into five groups. A PDAC molecular gradient (PAMG) was constructed from PDX transcriptomes recapitulating the five histological groups along a continuous gradient. The prognostic and predictive value for PMAG was evaluated in: i/ two independent series (n = 598) of resected tumours; ii/ 60 advanced tumours obtained by diagnostic EUS-guided biopsy needle flushing and iii/ on 28 biopsies from mFOLFIRINOX treated metastatic tumours. FINDINGS: A unique transcriptomic signature (PAGM) was generated with significant and independent prognostic value. PAMG significantly improves the characterization of PDAC heterogeneity compared to non-overlapping classifications as validated in 4 independent series of tumours (e.g. 308 consecutive resected PDAC, uHR=0.321 95% CI [0.207-0.5] and 60 locally-advanced or metastatic PDAC, uHR=0.308 95% CI [0.113-0.836]). The PAMG signature is also associated with progression under mFOLFIRINOX treatment (Pearson correlation to tumour response: -0.67, p-value < 0.001). INTERPRETATION: PAMG unify all PDAC pre-existing classifications inducing a shift in the actual paradigm of binary classifications towards a better characterization in a gradient. FUNDING: Project funding was provided by INCa (Grants number 2018-078 and 2018-079, BACAP BCB INCa_6294), Canceropole PACA, DGOS (labellisation SIRIC), Amidex Foundation, Fondation de France, INSERM and Ligue Contre le Cancer.

Validation of the QR1 Antibody for the Evaluation of PD-L1 Expression in Non-Small Cell Lung Adenocarcinomas.

The evaluation of Programmed cell Death Ligand 1 (PD-L1) expression in the tumor cells with immunohistochemistry is a mandatory diagnostic step in the treatment of lung cancer. It is important to utilize validated antibodies that can reliably detect PD-L1 positive cells. Different antibodies have already been studied. In this present study, we compared a new clone (QR1, Quartett) with reference clones to determine if it can be used in place of previously identified reference clones. We built a tissue micro array (TMA) from 110 lung adenocarcinomas and compared it using immunohistodetection of four different clones: QR1, 22c3, Sp263, and E1L3N. We analyzed the correlation between the sample duplicates for each clone and then a correlation and the concordance between the clones were calculated. A total of 101 patients were exploitable; the duplicates for each clone had a strong correlation. The correlation was the strongest (r=0.82) between QR1 and 22c3 and less strong with the other clones. Totals of 78%, 79%, and 97% of the QR1 cases were concordant with 22c3 for the thresholds of <1%, 1% to 49%, and ≥50%, respectively. The sensitivities and specificities of QR1, compared with 22c3, were >75% and 81%, respectively. PD-L1 expression, analyzed in lung adenocarcinomas with QR1, is highly correlated and concordant with the main reference clone used in most laboratories (22c3). It can be used to replace the latter in clinical routine.

Pancreatic Cancer Organoids for Determining Sensitivity to Bromodomain and Extra-Terminal Inhibitors (BETi).

Pancreatic ductal adenocarcinoma (PDAC) is a heterogeneous disease, therefore stratification of patients is essential to predict their responses to therapies and to choose the best treatment. PDAC-derived organoids were produced from PDTX and Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS-FNA) biopsies. A signature based on 16 genes targets of the c-MYC oncogene was applied to classify samples into two sub-groups with distinctive phenotypes named MYC-high and MYC-low. The analysis of 9 PDTXs and the corresponding derived organoids revealed that this signature which was previously designed from PDTX is transferable to the organoid model. Primary organoids from 24 PDAC patients were treated with NHWD-870 or JQ1, two inhibitors of c-MYC transcription. Notably, the comparison of their effect between the two sub-groups showed that both compounds are more efficient in MYC-high than in MYC-low samples, being NHWD-870 the more potent treatment. In conclusion, this study shows that the molecular signatures could be applied to organoids obtained directly from PDAC patients to predict the treatment response and could help to take the more appropriate therapeutic decision for each patient in a clinical timeframe.

Efficacy of Immune Checkpoint Inhibitors in KRAS-Mutant Non-Small Cell Lung Cancer (NSCLC).

INTRODUCTION: KRAS mutation is the most frequent molecular alteration found in advanced NSCLC; it is associated with a poor prognosis without available targeted therapy. Treatment options for NSCLC have been recently enriched by the development of immune checkpoint inhibitors (ICIs), and data about its efficacy in patients with KRAS-mutant NSCLC are discordant. This study assessed the routine efficacy of ICIs in advanced KRAS-mutant NSCLC. METHODS: In this retrospective study, clinical data were extracted from the medical records of patients with advanced NSCLC treated with ICIs and with available molecular analysis between April 2013 and June 2017. Analysis of programmed death ligand 1 (PD-L1) expression was performed if exploitable tumor material was available. RESULTS: A total of 282 patients with ICI-treated (in the first line or more) advanced NSCLC (all histological subgroups) who were treated with ICIs (anti-programmed death 1, anti-PD-L1, or anti-cytotoxic T-lymphocyte associated protein 4 antibodies), including 162 (57.4%) with KRAS mutation, 27 (9.6%) with other mutations, and 93 (33%) with a wild-type phenotype, were identified. PD-L1 analysis was available for 128 patients (45.4%), of whom 45.3% and 19.5% had PD-L1 expression of 1% or more and 50%, respectively (49.5% and 21.2%, respectively, in the case of the 85 patients with KRAS-mutant NSCLC). No significant difference was seen in terms of objective response rates, progression-free survival, or overall survival between KRAS-mutant NSCLC and other NSCLC. No significant differences in overall survival or progression-free survival were observed between the major KRAS mutation subtypes (G12A, G12C, G12D, G12V, and G13C). In KRAS-mutant NSCLC, unlike in non-KRAS-mutant NSCLC, the efficacy of ICIs is consistently higher, even though not statistically significant, for patients with PD-L1 expression in 1% or more of tumor cells than for those with PD-L1 expression in less than 1% of tumor cells, and this finding is especially true when PD-L1 expression is high (PD-L1 expression ≥50%). CONCLUSION: For patients with KRAS-mutant NSCLC (all mutational subtypes), the efficacy of ICI is similar to that for patients with other types of NSCLC. PD-L1 expression seems to be more relevant for predicting the efficacy of ICIs in KRAS-mutant NSCLC than it is in other types of NSCLC.

[Ovarian Sertoli-Leydig tumor: A tricky tumor]. / La tumeur de Sertoli-Leydig ovarienne : une tumeur qui peut être piégeuse.

We report the case of a 15 years old teenage girl presenting with a primary amenorrhea and hypervirilisation symptoms. The clinical assessement found a 16cm wide heterogenous ovarian mass testosteronemia and alpha-foeto protein levels were increased. On gross exam the tumor was solid and cystic, multilocular containing serous and mucinous liquids. Microscopically, there was a sertoli cells rich solid area in which the cells had a trabecular and nested organization with Leydig cells between them and there was also a cystic area made of glandular structures lined with an intestinal muco-secreting epithelium. Next to these area, there were Sertoli cells and an oedematous stroma. The immunostaining showed that the Sertoli cells expressed, among others, the inhibine and the glands expressed the cytokeratins 7 and 20. A Sertoli and Leydig cells tumor of intermediate differentiation with heterologous elements diagnostic was made. This is a rare tumor, representing less than 0.5% of ovary tumors. Well differentiated tumors are not frequent. In one third of the cases, there are hypervirilisation symptoms, the imaging exams will serve to narrow the diagnosis and to do a full work-up to establish an extension. There are several histologic sub types caracterised by the existence of retiforms structures or heterologous elements. There are no specific immunostainings, this will only help to narrow the diagnosis and rule out some hypothesis. There are no guidelines for the management of the patients, indeed each center has its own practices. Those tumors have quite a good prognosis thanks to their early diagnosis at a stade where they are still confined to the ovary.

[An ovarian tumor can hide another one]. / Une tumeur ovarienne peut en cacher une autre.

We report the case of a 33-year-old woman who went under surgery for a cystic mature teratoma. The histological exam found two cysts, one was a mature teratoma and the other was a struma ovarii with a papillary carcinomatous element. Struma ovarii cancerization is seen in 5 to 10% of the cases usually under a papillary carcinoma type. Diagnosis is rarely made before surgery, the patients exceptionally show thyroid symptoms. Histologically, the tumour presents the same way as the one seen in the thyroid gland and BRAF mutations have been reported. The problem concerns ovarian metastases of a thyroid cancer. A normal thyroid check up and normal thyroid tissue close to the tumor in the ovary are in favor for a cancerize struma ovarii. The therapeutic care is not consensual, going from an annexectomy to hysterectomy and bilateral annexectomy. The patients must be followed on long-term with thyroglobulin quantitative analysis for at least 10 years and whole body scintigraphy with iodine 123 to detect relapse or metastases. The prognosis is usually good but precise criteria are still to define.

Is negative multiparametric magnetic resonance imaging really able to exclude significant prostate cancer? The real-life experience.

OBJECTIVES: To evaluate the histopathological results after radical prostatectomy (RP) in patients that had normal preoperative multiparametric magnetic resonance imaging (mpMRI), in order to determine whether they had significant or insignificant disease. Moreover, we evaluated the influence of the expertise of the radiologist on the results. PATIENTS AND METHODS: We retrospectively included patients who underwent RP in our centre and who had a preoperative negative mpMRI. The MRIs were considered negative when no suspicious lesion was seen or when the Prostate Imaging Reporting and Data System version 1 score was <7. We used Pathological tumour-node-metastasis staging and Gleason score on pathology reports, and whole-mount sections to calculate tumour volume. RESULTS: We identified 101 patients from 2009 to 2015. Final pathology showed that 16.9% had extraprostatic extension, 13.8% had primary Gleason pattern 4 (4 + 3 and above), 47.5% had secondary Gleason pattern 4 or 5, and 55.9% and 20.6% had a main tumour volume of ≥0.5 and ≥2 mL, respectively. When limiting the analysis to expert reading only, the numbers improved: only one patient (3.4%) had extraprostatic extension (P < 0.05), one patient (3.4%) had primary Gleason pattern 4 (P = 0.05), and 64.7% and 5.9% had a main tumour volume of ≥0.5 and ≥2 mL, respectively (P = 0.01). CONCLUSION: A negative MRI does not guarantee the absence of significant prostate cancer.

[A solid variant of a serous cystadenocarcinoma of the pancreas]. / Un cystadénocarcinome séreux du pancréas dans une variante solide.

Cystic pancreatic neoplasms concern 1 to 2% of the pancreatic tumours. The serous ones are considered benign tumours but since 1989, several pancreatic serous cystadenocarcinomas (SCAC) cases have been reported. We report the case of a SCAC with a particular pattern. An 80-year-old female patient presented a 4-cm tumour in the neck of the pancreas associated with liver lesions evoking, on imagery exams, focal nodular hyperplasia nests. A cephalic duodenopancreatectomy and a resection of the liver lesions were carried out. The gross exam showed a tumour with a pattern mostly solid and an area made of cysts. The microscopic exam displayed two patterns: the solid one, predominant, made of mild atypical clear cells, and the cystic one. The liver lesions revealed solid pattern similar to the pancreatic tumour one. The tumoral cells were cytokeratin 7, AE1/AE3 and inhibin positives. The Periodic-acid Schiff showed cytoplasmic granulations, which were digested after diasatasis. Only the presence of metastases allows distinguishing a pancreatic serous cystadenoma from a SCAC. To date, thirty cases of pancreatic SCAC have been reported. Immunohistochemistry cannot confirm the malignancy nature of the lesion but it needs to be done in order to cross out the differential diagnosis, that is pancreatic metastatic clear cell renal carcinoma. Nevertheless, it remains a pathology with good prognosis. Only two cases have been reported but ours case a predominant solid pattern.

[The colloid milium: An observation associated with trichinosis]. / Milium colloïde : une observation associée à une trichinose.

The colloid milium has four clinical forms: adult colloid milium, juvenile colloid milium, paracolloid (or nodular colloid degeneration) and pigmented colloid milium. We report the case of an adult colloid milium in a man of 56, who presented episodes of diffuse pruritus associated with myalgia and digestive disorders, indicative of trichinosis. He also developed gradually over the past 10 years, yellowish injuries in the mandibles and neck for whom histology objectified a colloid milium. Etiology and treatment are still unknown; association with a trichinosis is probably coincidental.