Study On Efficacy And The Tumor Microenvironment Of Beneficial Population Of Immunotherapy Combined With Anti-angiogenesis Therapy In Advanced NSCLC Patients

Background and objective:Immunotherapy has made great progress in non-small cell lung cancer（NSCLC）in the past decade.Although programmed cell death protein 1（PD-1）inhibitors have been approved as standard treatment for NSCLC patient.However,the benefit of immunotherapy monotherapy is limited and the efficacy still needs to be further improved.Immune checkpoint inhibitors（ICIs）combined with other drugs is a hot spot in clinical research,such as combined with anti-angiogenic drugs.A large number of basic research and clinical trials have provided support for immunotherapy combined with anti-angiogenesis.In the real world,immunotherapy combined with anti-angiogenesis is also commonly used in NSCLC patients,but the efficacy and safety of these patients need to be further explored.Therefore,based on real-world clinical data,this study will explore the safety and efficacy of ICIs combined with anti-angiogenic drugs in advanced NSCLC patients,and analyze the components of TME before treatment in patients benefiting from combination therapy by multiple immunofluorescence staining.To provide more evide nce for the use of ICIs combined with anti-angiogenic drugs in the treatment of advanced NSCLC patients.Methods:Advanced NSCLC patients diagnosed from December 2019 to January 2021 in the Cancer Center of the Renmin Hospital of Wuhan University hospital were collected.The enrolled patients were divided into two groups: ICIs combined with anti-angiogenic drugs（the treatment group）and ICIs not combined with anti-angiogenic drugs（the control group）.Then,clinical data and peripheral blood index data of these patients were collected.Peripheral blood indexes mainly include:neutrophil-to-lymphocyte ratio（NLR）,platelet-to-lymphocyte ratio（PLR）,albumin（ALB）and lactate dehydrogenase（LDH）.Chi-square test was used to compare the baseline characteristics between the treatment group and the control group.Kaplan-meier method was used to obtain survival information and survival curve.Log-rank test and Cox regression analysis were used to evaluate the effects of different variables on the prognosis of advanced NSCLC patients treated with ICIs combined with anti-angiogenic drugs.Multiplex immunofluorescence staining was used to analyze the relationship between the efficacy of immunotherapy combined with anti-angiogenesis therapy and TME in advanced NSCLC patients.Results:A total of 190 patients met the inclusion criteria,including 96 in the treatment group and 94 in the control group.There were no statistically significant differences in baseline characteristics between the two groups.The ORR and DCR of the treatment group were 39.6% and 82.3%,respectively,higher than 25.5% and 75.5%of the control group,but only the ORR had a statistical difference（P=0.039）.The results of survival analysis showed that the median PFS in the treatment group was longer than that in the control group（9.7 vs 8.6 months）,but there was no significant difference（P=0.101）.Subgroup analysis found that the combination of ICIs and anti-angiogenic drugs in the first-line can significantly prolong PFS in advanced NSCLC patients（12.0 vs 8.2 months,P = 0.038）.In addition,we also found that PFS was significantly prolonged in patients with brain metastases in the treatment group（9.6 vs 6.1 months,P=0.028）,while there was no significant difference in PFS between the two groups in patients without brain metastases（9.7 vs 9.6 months,P=0.207）.In the treatment group,the most common adverse events were thrombocytopenia（38.5%）and fatigue（45.8%）,while nausea and vomiting（6.2%）and immune pneumonia（7.3%）were relatively rare.By analyzing the relationship between the dynamic changes of patients’ peripheral blood indexes and their clinical prognosis,we found that patients with decreased NLR at 6 or 12 weeks after treatment had longer PFS（6w: 10.8 vs 7.7months,P=0.012;12w: 12.0 vs 8.0 months,P=0.014）,and similar results were found in those with decreased PLR（6w: 10.8 vs 7.7 months,P=0.019;12w: 14.0 vs 8.3months,P=0.013）.However,the dynamic changes of ALB（6w: 8.0 vs 10.3 months,P=0.071;12w: 10.3 vs 11.7 months,P=0.759）and LDH（6w: 9.7 vs 9.6 months,P=0.937;12w: 11.7 vs 9.7 months,P=0.127）was not correlated with PFS.Multiple immunofluorescence staining of pathological sections of advanced NSCLC patients receiving immunotherapy combined with anti-angiogeneis therapy showed that PNAD,CD3,CD20,CD21 and CD23 markers were abundant in the TME of patients who responded to combination therapy,while these markers were scarce in the TME of ineffective patients.In addition,we quantitatively analyzed the tumor-infiltrating lymphocytes in the TME of the patients and found that compared with the patients who did not respond to the combination therapy,the TME of the patients who responded to the treatment were enriched in CD4,CD8 and TCF1 markers,with an average count of 481,365 and 622,respectively.Whereas FOXP3 markers are rare,with an average count of 129.Conclusions:Immunotherapy combined with anti-angiogenesis therapy has good efficacy and safety in the real world in the treatment of advanced NSCLC patients.Combining ICIs with anti-angiogenic drugs in the first-line can significantly prolong the PFS of patients,especially in those with brain metastases.The dynamic changes of peripheral blood indexes NLR and PLR after immunotherapy combined with anti-angiogenesis therapy can be used as an independent prognostic indicators for advanced NSCLC patients.In addition,this study also found that immune effector cells and normal vascular endothelial cells were abundant in TME of patients benefiting from combination therapy,while immunosuppressive cells were scarce,which further provided a basis for the mechanism study of combination therapy.