Naiyer Rizvi, MD, Omid Hamid, MD, Solange Peters, MD, PhD, Thomas Powles, MBBS, MRCP, MD, and Nadeem Riaz, MD, MSc, prepared useful Practice Aids pertaining to immuno-oncology for this CME activity titled "Emerging Biomarkers, New Targets, and Rational Combinations: Are We on the Verge of the Next Generation of Immuno-Oncology?" For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2H2s92Y. CME credit will be available until June 17, 2019.

1. CD: cluster of differentiation; ctDNA: circulating tumor DNA; HLA: human leukocyte antigen; TCR: T-cell receptor; TMB: tumor mutational burden; UV: ultraviolet.
1. Hellmann MD et al. N Engl J Med. 2018. doi:10.1056/NEJMoa1801946. 2. Carbone DP et al. N Engl J Med. 2017:376;2415-2426. 3. Hellmann MD et al. Cancer Cell. 2018. doi: https://doi.org/10.1016/j.ccell.2018.03.018. Epub. 4. Ramalingam S et al. American Association for Cancer
Research Annual Meeting 2018 (AACR 2018). Abstract CT078. 5. Snyder A et al. N Engl J Med. 2014;371:2189-2199. 6. Rizvi NA et al. Science. 2015;348:124-128. 7. Le DT et al. N Engl J Med. 2015;372:2509-2520. 8. Van Allen EM et al. Science. 2015;350:207-211. 9. Hugo W et al. Cell.
2016;165:35-44. 10. Yarchoan M et al. N Engl J Med. 2017;377:2500-2501.
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
CANCER IMMUNOTHERAPY BIOMARKERS
TUMORMUTATIONALBURDEN(TMB)1-10
PRACTICE AID
Access the activity,“Emerging Biomarkers, NewTargets, and Rational Combinations: AreWe on theVerge of the Next Generation of Immuno-Oncology?,”
at www.peerview.com/ETR40.
WHAT IS TMB?
TMB = collective number of somatic
mutations within the tumor’s genome
Highly mutated tumors are more likely to
harbor neoantigens → ↑ immunogenicity
TMB
HOW TO TEST FOR TMB?
WHY TEST FOR TMB?
Tissue biopsy–based assessments
q Whole exome sequencing
q Targeted comprehensive
genomic profiling
(more feasible option for routine
use in practice)
Liquid biopsy–based assessments
q Isolating and detecting cell-free ctDNA
q ↑ in tumor-specific
neoantigens → ↑ in # of
tumor-infiltrating immune cells
q Activated & primed CD8+
cytotoxic T cells can recognize
& target neoantigens that are
peptide-bound to major
histocompatibility complex
class I & presented on tumor
cells → anti-tumor immune
response → tumor cell lysis
q ↑ Mutational load =
↑ neoantigens → ↑ response
to immune checkpoint inhibitors
q Response rates across
cancers correlate with TMB
q Predictive, not prognostic,
biomarker
q Clonality, neoantigen prediction,
and patient HLA genotype will likely
improve TMB in the near future
Abnormal activity in cellular pathways
(eg, DNA damage repair, DNA replication)
and exposure to mutagens (UV light,
tobacco smoke) can ↑ the overall rate of
somatic mutations in tumors
Neoantigens
TCR
Neoantigen
presentation
Tumor cell Killer
T cellDNA
mutations
HLA
1
2
3
4
5
6
78
9
10
11
12
13
14
15
16
17
18
19
20 21 22
TMB is a pan-tumor immuno-oncology biomarker
Measured as total number of mutations
or mutations per megabase
Type of mutations counted usually is
missense
Thresholds for high vs low TMB are still in
flux and depend on the assay and histology
– TMB-high cut-point in CheckMate -227:
≥10 mut/Mb
TMB levels
vary in different
types of tumors
LUNG SKIN BLADDER
High-TMB cancers
But % of many other cancers found
to be TMB-high also → opportunity to
expand indications for immunotherapies

2. CRC: colorectal cancer; dMMR: mismatch repair deficient; EXO: exonuclease; IHC: immunohistochemistry; MLH1: mutL homolog 1; MLH3: mutL homolog 3; MMR: mismatch repair; MSH2: mutS homolog 2; MSH3: mutS homolog 3; MSH6: mutS homolog 6; MSI: microsatellite
instability; MSI-H: microsatellite instability high; NGS: next-generation sequencing; PCR: polymerase chain reaction; POL: polymerase.
1. Vilar E, Gruber SB. Nat Rev Clin Oncol. 2010;7:153-162. 2. Hause RJ et al. Nat Med. 2016;22:1-9. 3. Bogaert J, Prenen H. Ann Gastroenterol. 2014;27:9-14. 4. Giannakis M et al. Cell Rep. 2016;15:857-865. 5. McGranahan N et al. Science. 2016;351:1463-1469. 6. https://www.fda.gov/Drugs/
InformationOnDrugs/ApprovedDrugs/ucm569366.htm. Accessed April 5, 2018. 7. https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm560040.htm. Accessed April 5, 2018.
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
Access the activity,“Emerging Biomarkers, NewTargets, and Rational Combinations: AreWe on theVerge of the Next Generation of Immuno-Oncology?,”
at www.peerview.com/ETR40.
CANCER IMMUNOTHERAPY BIOMARKERS
MICROSATELLITEINSTABILITY(MSI)/MISMATCHREPAIR(MMR)1-7
PRACTICE AID
WHAT IS MSI/MMR?
Microsatellite instability high or deficient
mismatch repair (MSI-H/dMMR) status
MSI-H/dMMR tumors → ↑ neoantigens → ↑ immunogenicity
HOW TO TEST FOR MSI/MMR?
WHY TEST FOR MSI/MMR?
MSI status
q Polymerase chain reaction (PCR)
Indicators of genomic instability
q MSI-H: Change in # of nucleotide repeats
in DNA sequences → different number of
repeats than in inherited DNA
q dMMR: Loss of function in the MMR pathway,
a key DNA repair system
MMR status
q Immunohistochemistry (IHC)
MSI-H/dMMR status predicts benefit from immune
checkpoint inhibitors; FDA-approved options:
Alternative method
q Next-generation sequencing (NGS)
q Patients ≥12 yrs with MSI-H or dMMR metastatic CRC that has progressed
following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan
Nivolumab
q Unresectable/metastatic MSI-H or dMMR solid tumors that have
progressed following prior treatment and who have no satisfactory
alternative treatment options
q MSI-H or dMMR CRC that has progressed following treatment with
a fluoropyrimidine, oxaliplatin, and irinotecan
Adult and pediatric patients with:
EXO
3’ → 5’ EXO
proofreading
3’ → 5’ EXO
proofreading
SlippageMispair
POL
error
(10-4
-10-5
)
Error
extension
(slow)
MMR MMR
POL
Apoptosis
DNA
damage
PMS2MLH1
MSH2
MutSα
MSH6
PMS2MLH1
MSH2
MutSα
MSH6
MLH3MLH1
MSH2
MutSβ
or
or
MSH3
MSI-H/dMMR
tumors have
high mutational
burden
Pembrolizumab
MSI
MMR
↑ neoantigens
→ ↑ T-cell activation
& immune cell
infiltration of tumor
microenvironment

3. IHC: immunohistochemistry; PD-1: programmed cell death protein 1; PD-L1: programmed death ligand 1; PD-L2: programmed death-ligand 2.
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.
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
Access the activity,“Emerging Biomarkers, NewTargets, and Rational Combinations: AreWe on theVerge of the Next Generation of Immuno-Oncology?,”
at www.peerview.com/ETR40.
CANCER IMMUNOTHERAPY BIOMARKERS
PROGRAMMEDDEATH-LIGAND1(PD-L1)EXPRESSION1-4
PRACTICE AID
WHAT IS PD-L1?
PD-L1: a ligand for the immune checkpoint receptor
programmed cell death protein 1 (PD-1) expressed
on the surface of cytotoxic T cells
HOW TO TEST FOR PD-L1?
WHAT ARE THE PITFALLS OF PD-L1 TESTING?
PD-L1 expression can be measured by an
immunohistochemistry (IHC) assay and
detected on tumor and immune cells
Between 0% and 100% of tumor cells within
a sample can express PD-L1
q Focal PD-L1 expression in some tumors may be missed in small biopsy specimens
q PD-L1 expression among multiple tumor lesions from individual patients can vary over time and by anatomical site
q PD-L1 expression in tumor biopsies collected months or years earlier might not accurately reflect PD-L1 status at the time of treatment initiation
q Antibodies used for PD-L1 detection have different affinities and specificities
q PD-L1 epitopes detected by some antibodies can be unstable with prolonged specimen fixation or inadequate tissue handling
q PD-L1 protein expression can be membranous and/or cytoplasmic, but only membranous PD-L1 is functionally relevant when in contact with PD-1+ T cells
q PD-L1 can be expressed by multiple cell types within the tumor microenvironment, which makes scoring and interpretation challenging
DRUG DIAGNOSTIC
Complementary:
PD-L1 IHC 28-8 pharmDx test
PD-L1
expression
Nivolumab
Companion:
PD-L1 IHC 22C3 pharmDx test
Pembrolizumab
Complementary:
Ventana PD-L1 SP142 assay
Atezolizumab
Complementary:
Ventana PD-L1 SP263 assay
Durvalumab
PD-L1
PD-L2
PD-1
T cell
Tumor cell