Kurt Schalper, MD, PhD, and Edward Garon, MD, MS, prepared useful Practice Aids pertaining to immuno-oncology biomarkers for this CME/MOC activity titled "Advances and Challenges in Refining the Use of Cancer Immunotherapies Through Biomarker Testing: Practical Guidance for Pathologists on the Front Lines of the Immuno-Oncology Revolution." For the full presentation, monograph, complete CME/MOC information, and to apply for credit, please visit us at http://bit.ly/2DE3X9J. CME/MOC credit will be available until December 2, 2019.

1. Access the activity, “Advances and Challenges in Refining the Use of Cancer Immunotherapies
Through Biomarker Testing: Practical Guidance for Pathologists on the Front Lines of the
Immuno-Oncology Revolution,” at www.peerview.com/BNF40.
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice.
CRC: colorectal cancer; CSCC: cutaneous squamous cell carcinoma; dMMR: mismatch repair deficient; HCC: hepatocellular carcinoma; HNSCC: head and neck squamous cell carcinoma; MSI-H: microsatellite
instability high; PD-L1: programmed death-ligand 1; RCC: renal cell carcinoma; SCLC: small cell lung cancer.
1. https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm279174.htm. Accessed September 19, 2018.
IMMUNE CHECKPOINT
INHIBITOR LANDSCAPE:
FDA Approvals and Indications
in Solid Tumors1
2011
2015
2017
2014
2016
2018
PRACTICE AID
March
Ipilimumab (melanoma)
March
Nivolumab (squamous NSCLC, second line)
October
Nivolumab (nonsquamous NSCLC, second line)
Pembrolizumab (PD-L1+ NSCLC , second line)
Nivolumab + ipilimumab (melanoma, first line)
Ipilimumab (melanoma, adjuvant)
November
Nivolumab (RCC)
December
Pembrolizumab (melanoma, first line)
January
Nivolumab (bladder)
March
Avelumab (Merkel cell carcinoma)
May
Durvalumab, avelumab, pembrolizumab (bladder)
Pembrolizumab + chemotherapy
(nonsquamous NSCLC, first line)
Pembrolizumab (MSI-H cancers)
August
Nivolumab (dMMR/MSI-H CRC)
September
Pembrolizumab (gastric)
Nivolumab (HCC)
December
Nivolumab (melanoma, adjuvant)
September
Pembrolizumab (melanoma)
December
Nivolumab (melanoma)
May
Atezolizumab (bladder)
August
Pembrolizumab (HNSCC)
October
Pembrolizumab (PD-L1+ NSCLC, first line)
Atezolizumab (NSCLC, second line)
November
Nivolumab (HNSCC)
February
Durvalumab (stage III NSCLC)
April
Nivolumab + ipilimumab (RCC, first line)
June
Pembrolizumab (PD-L1+ cervical)
July
Nivolumab + ipilimumab (dMMR/MSI-H CRC)
August
Nivolumab (SCLC, third line)
Pembrolizumab + chemotherapy
(nonsquamous NSCLC, first line—full approval)
September
Cemiplimab-rwlc (CSCC)
October
Pembrolizumab + chemotherapy (squamous
NSCLC, first line)
November
Pembrolizumab (HCC, second line)

2. Access the activity, “Advances and Challenges in Refining the Use of Cancer ImmunotherapiesThrough BiomarkerTesting: Practical Guidance for
Pathologists on the Front Lines of the Immuno-Oncology Revolution,” at www.peerview.com/BNF40.
KEY IMMUNO-ONCOLOGY BIOMARKERS
An Overview of PD-L1, MSI/MMR, and TMB
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice.
• PD-L1: A ligand for the immune checkpoint receptor programmed cell
death protein 1 (PD-1) expressed on the surface of cytotoxic T cells
• Between 0% and 100% of tumor cells within a sample can express PD-L1
• PD-L1 expression can be measured by an immunohistochemistry (IHC) assay and detected
on tumor and immune cells
o Nivolumab"PD-L1 IHC 28-8 pharmDx test
o Pembrolizumab"PD-L1 IHC 22C3 pharmDx test
o Atezolizumab"Ventana PD-L1 SP142 assay
o Durvalumab"Ventana PD-L1 SP263 assay
What is PD-L1?
PD-L1
expression1-4
How to test for PD-L1?
PD-L1
PD-L2
PD-1
T cell
Tumor cell

3. Access the activity, “Advances and Challenges in Refining the Use of Cancer ImmunotherapiesThrough BiomarkerTesting: Practical Guidance for
Pathologists on the Front Lines of the Immuno-Oncology Revolution,” at www.peerview.com/BNF40.
KEY IMMUNO-ONCOLOGY BIOMARKERS
An Overview of PD-L1, MSI/MMR, and TMB
PRACTICE AID
• Microsatellite instability high or deficient mismatch repair (MSI-H/dMMR) status; indicators of
genomic instability:
– MSI-H: Change in number of nucleotide repeats in DNA sequences " different number of
repeats than in inherited DNA
– dMMR: Loss of function in the MMR pathway, a key DNA repair system
• FDA-approved pan-cancer biomarker for pembrolizumab, and in mCRC, for nivolumab and
nivolumab + ipilimumab
MSI status
o Polymerase chain reaction (PCR)
MMR status
o Immunohistochemistry (IHC)
Alternative method
o Next-generation sequencing (NGS)
What is MSI/MMR?
MSI-MMR5-11
How to test for MSI/MMR?

4. dMMR: mismatch repair deficient; IHC: immunohistochemistry; mCRC: metastatic colorectal cancer; MMR: mismatch repair; MSI: microsatellite instability; MSI-H: microsatellite instability high; NGS: next-generation sequencing; PCR: polymerase chain reaction; PD-1: programmed
cell death protein 1; PD-L1: programmed death ligand 1; PD-L2: programmed death ligand 2; TMB: tumor mutational burden.
1. Gatalica Z et al. Cancer Epidemiol Biomarkers Prev. 2014;23:2965-2970. 2. Taube JM et al. Clin Cancer Res. 2014;20:5064-5074. 3. Kerr KM et al. J Thorac Oncol. 2015;10:985-989. 4. Topalian SL et al. Nat Rev Cancer. 2016;16:275-287. 5. Vilar E, Gruber SB. Nat Rev Clin Oncol. 2010;7:153-162.
6. Hause RJ et al. Nat Med. 2016;22:1-9. 7. Bogaert J, Prenen H. Ann Gastroenterol. 2014;27:9-14. 8. Giannakis M et al. Cell Rep. 2016;15:857-865. 9. McGranahan N et al. Science. 2016;351:1463-1469. 10. https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm569366.
htm. Accessed August 28, 2018. 11. https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm560040.htm. Accessed August 28, 2018. 12. Snyder A et al. N Engl J Med. 2014;371:2189-2199. 13. Rizvi NA et al. Science. 2015;348:124-128. 14. Le DT et al. N Engl J Med.
2015;372:2509-2520. 15. Van Allen EM et al. Science. 2015;350:207-211. 16. Hugo W et al. Cell. 2016;165:35-44. 17. Carbone DP et al. N Engl J Med. 2017;376:2415-2426. 18. Yarchoan M et al. N Engl J Med. 2017;377:2500-2501.
Access the activity, “Advances and Challenges in Refining the Use of Cancer ImmunotherapiesThrough BiomarkerTesting: Practical Guidance for
Pathologists on the Front Lines of the Immuno-Oncology Revolution,” at www.peerview.com/BNF40.
KEY IMMUNO-ONCOLOGY BIOMARKERS
An Overview of PD-L1, MSI/MMR, and TMB
PRACTICE AID
• TMB = collective no. of somatic mutations within the tumor’s genome; TMB levels vary in different tumors
# Mutational load = # neoantigens " # response to immune
checkpoint inhibitors in some tumors
• Measured as total number of mutations or mutations per megabase
• Type of mutations counted usually is missense
• Thresholds for high vs low TMB still in flux; depend on assay + histology
• Complementary to PD-L1—identifies a distinct population of patients
Tissue biopsy–based assessments
o Targeted comprehensive genomic profiling
Liquid biopsy–based assessments
o Isolating and detecting cell-free ctDNA
LUNG SKIN BLADDER
High-TMB cancers
What is TMB?
TMB12-18
How to test for TMB?

5. IHC: immunohistochemistry; PD-1: programmed cell death protein 1; PD-L1: programmed death ligand 1.
1. Gatalica Z et al. Cancer Epidemiol Biomarkers Prev. 2014;23:2965-2970. 2. Taube JM et al. Clin Cancer Res. 2014;20:5064-5074. 3. Kerr KM et al. J Thorac Oncol. 2015;10:985-989. 4. Topalian SL et al. Nat Rev Cancer. 2016;16:275-287. 5. https://www.fda.gov/drugs/informationondrugs/
approveddrugs/ucm279174.htm. Accessed September 19, 2018.
Access the activity, “Advances and Challenges in Refining the Use of Cancer ImmunotherapiesThrough BiomarkerTesting: Practical Guidance for
Pathologists on the Front Lines of the Immuno-Oncology Revolution,” at www.peerview.com/BNF40.
TESTING FOR PD-L1 EXPRESSION AS A KEY
IMMUNO-ONCOLOGY BIOMARKER
Complementary and Companion Diagnostics1-5
PRACTICE AID
Result required for prescription of drug
• Specified on drug label
• Category typically only required when the test is among inclusion criteria for the trial
Test result is predictive, but not required for prescription of drug
• Nice to have, but do not need to have
• Category mostly used when the assay is integrated into the trial, but not used among inclusion criteria
Companion vs Complementary Diagnostic Assays
Immune Checkpoint Inhibitors and Associated PD-L1 Assays
Durvalumab
Target: PD-L1Diagnostic:
Ventana PD-L1
SP263 assay
Designation:
Complementary
Urothelial cancer
(1st line)
Atezolizumab
Target: PD-L1Diagnostic:
Ventana PD-L1
SP142 assay
Designation:
Companion
Gastric/GEJ
adenocarcinoma
(2nd line)
NSCLC
(1st-2nd line)
Urothelial cancer
(1st line)
Cervical cancer
(2nd line)
Pembrolizumab
Designation:
Companion
Target: PD-1Diagnostic:
PD-L1 IHC 22C3
pharmDx test
Target: PD-1
Nivolumab
Diagnostic:
PD-L1 IHC 28-8
pharmDx test
Designation:
Complementary
Companion
Complementary
Urothelial cancer
(2nd line)
NSCLC
(2nd line)
Melanoma
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice.