Monitoring immunE DysregulAtion foLLowing Immune checkpOint-inhibitioN (MEDALLION): protocol for an observational cancer immunotherapy cohort study

Abstract

Background: Checkpoint inhibitors (CPIs) are widely used in cancer treatment, with transformative impacts on survival. They nonetheless carry a significant risk of toxicity in the form of immune-related adverse events (IrAEs), which may be sustained and life-altering. IrAEs may require high-dose and/or prolonged steroid use and represent a significant healthcare burden. They mimic immune-mediated inflammatory diseases (IMIDs) but understanding of their pathogenesis is limited. The MEDALLION project aims to determine targetable mechanisms of immune dysregulation in IrAE development, employing an immune monitoring approach to determine changes in circulating and tissue resident cells of CPI recipients who do/do not develop them and assessing the contribution of the microbiome in parallel.

Methods: MEDALLION is a non-randomised longitudinal cohort study aiming to recruit 66 cancer patient recipients of anti-PD1/PD-L1, anti-CTLA-4 or combination therapy. Eligible participants include those with malignant melanoma in the adjuvant or metastatic setting, mesothelioma and non-small cell lung carcinoma (NSCLC) treated in the metastatic setting. Comprehensive clinical evaluation is carried out alongside blood, skin swab and stool sampling at the time of CPI initiation (baseline) and during subsequent routine hospital visits on 6 occasions over a 10-month follow-up period. It is conservatively anticipated that one third of enrolled patients will experience a "significant IrAE" (SirAE), defined according to pre-determined criteria specific to the affected tissue/organ system. Those developing such toxicity may optionally undergo a biopsy of affected tissue where appropriate, otherwise being managed according to standard of care. Peripheral blood mononuclear cells will be analysed using multi-parameter flow cytometry to investigate immune subsets, their activation status and cytokine profiles. Stool samples and skin swabs will undergo DNA extraction for 16 S ribosomal RNA (rRNA) sequencing and internal transcribed spacer (ITS) gene sequencing to determine bacterial and fungal microbiome diversity, respectively, including species associated with toxicity. Stored tissue biopsies will be available for in situ and single-cell transcriptomic evaluation. Analysis will focus on the identification of biological predictors and precursors of SirAEs.

Discussion: The pathogenesis of IrAEs will be assessed through the MEDALLION cohort, with the potential to develop tools for their prediction and/or strategies for targeted prevention or treatment.

Trial registration: The study was registered on 18/09/2023 in the ISRCTN registry (43,419,676).

Keywords: Cancer; Checkpoint inhibitor; Cohort study; Immune related adverse events; Immunotherapy; Pathogenesis.

Fig. 1

Spontaneous immune mediated disease and MEDALLION study hypothesis. Established immune-mediated diseases are well-studied, and their risk factors are increasingly understood in the general population (left panel). In cancer patients, we hypothesise that checkpoint blockade actively “lowers the threshold” at which immune tolerance is lost, permitting systematic monitoring of the events that trigger clinically manifest disease (right panel). The MEDALLION cohort represents a human “model” of incipient immune dysregulation within which we will test this hypothesis.)

Fig. 2

MEDALLION enrolment plan and design. Clinical assessments will take place at all patient visits, planned to coincide with routine hospital visits, and red arrows indicate time points at which 53 ml research bloods will be drawn (providing irAE has not occurred); additional research bloods +/- biopsy will be obtained at the time of incident SirAE)