Spatial biomarkers of response to neoadjuvant therapy in muscle-invasive bladder cancer: the DUTRENEO trial

Abstract Many studies have reported biomarkers predictive of response to immune checkpoint inhibitors (ICI) based on retrospective analyses. However, few clinical trials have tested their value prospectively. The DUTRENEO trial (EudraCT: 2017-002246-6) investigated whether an 18-gene Tumour Inflammation Signature (TIS) that can robustly identify patients who respond to ICI in multiple tumour types could stratify patients with localized muscle-invasive bladder cancer (MIBC) to receive neoadjuvant ICI (durvalumab+tremelimumab) or standard cisplatin-based neoadjuvant chemotherapy (NAC). Patients with TIS-high tumors were randomized to ICI or NAC, while patients with TIS-low tumors received NAC. A total of 73 patients were treated. Pathological complete response (pCR) rates were 38.5% (TIS-High, ICI), 30% (TIS-High, NAC), and 55% (TIS-Low, NAC) (p = 0.349), indicating that - as applied - the TIS score did not significantly enrich in responders to ICI. Post-hoc analysis showed that higher TIS thresholds improved prediction of response to ICI but excluded many responders. Multi-omics analyses of pre-treatment samples, including whole-exome sequencing, bulk RNA sequencing, and spatial transcriptomics (Visium, Xenium), revealed that bulk RNA response signatures originated mainly from cancer cells. Spatial transcriptomics showed that ICI response was associated with proximity between cancer cells and adaptive immune cells, while resistance to NAC was linked to phenotypic plasticity of cancer cells despite low genetic diversity. The unique design of the DUTRENEO trial underscores the challenges of translating retrospective biomarkers into clinical practice and highlights the importance of spatial features in understanding tumour-immune interactions. These findings suggest that integrating spatial and multi-modal biomarkers in well-designed clinical trials could improve stratification and response prediction to select neoadjuvant therapy. Competing Interest Statement EG has received honoraria for speaker engagements, advisory roles or funding of continuous medical education from Adacap, AMGEN, Angelini, Astellas, Astra Zeneca, Bayer, Blueprint, Bristol Myers Squibb, Caris Life Sciences, Celgene, Clovis-Oncology, Eisai, Eusa Pharma, Genetracer, Guardant Health, HRA-Pharma, IPSEN, ITM-Radiopharma, Janssen, Lexicon, Lilly, Merck KGaA, MSD, Nanostring Technologies, Natera, Novartis, ONCODNA (Biosequence), Palex, Pharmamar, Pierre Fabre, Pfizer, Roche, Sanofi-Genzyme, Servier, Taiho, and Thermo Fisher Scientific. OR has received honoraria for speaker engagements, advisory roles or funding of continuous medical education from Astellas, Bristol Myers Squibb, IPSEN, Pfizer, and MSD. DC has received honoraria for consulting or advisory role of CME from Pfizer, Novartis, Astra-Zeneca, Astellas, Bayer, Bristol Myers-Squibb, Eisai, Eusa Pharma, MSD, Merck KG&A, Roche, Gilead, Ipsen, Janssen, Excelisis, Genentech. JP has received honoraria for speaker engagements, advisory roles or funding of continuous medical education from Astellas, Astra Zeneca, Bayer, Bristol Myers Squibb, Eisai, Eusa Pharma, IPSEN, Janssen, Merck KGaA, MSD, Novartis, Pfizer, Roche and Gilead. JP has received research grants from Pfizer, Astellas, and Merck. AF has received honoraria for an advisory council or committee from Janssen, Astellas, Bayer, Merck, EUSA;received grants or funds from AstraZeneca, Roche, Astellas and travel accommodation fees from Janssen, Bristol-Myers Squibb, Merck, Roche. TAG funding, honoraria, and nonfinancial or other support from IPSEN, Adacap, Pfizer, Sanofi, EISAI, Lilly, Bayer, Johnson&Johnson, Astellas, Novartis, Roche. XGM has received honoraria for speaker engagements or advisory roles from Astellas, Bristol Myers Squibb, Deciphera, Eisai, GSK, IPSEN, Merck KGaA, MSD, Pharmamar, Pfizer, Recordati, and Roche. XG has received research grants from AstraZeneca and Incyte. FGR has received grants/research funding from Combat Medical and Roche; clinical trials with UroGen, Pharmalink, Astellas, Johnson and Johnson, Roche, Combat Medical, Taris Bio, Janssen, Pfizer, AstraZeneca, Bristol Myers Squibb, Seagen, Fidia and Cepheid; consulting/advisory fees from Pfizer, AstraZeneca, Johnson and Johnson, Nucleix, Taris Bio, Bristol Myers Squibb, Roche, Combat Medical, and Janssen; honoraria/speaker fees from Taris Bio, Combat Medical, Nucleix, Palex, Astellas, Bristol Myers Squibb, Merck, Janssen, AstraZeneca and Pfizer; and travel support from Johnson and Johnson, AstraZeneca, Janssen, Ipsen and Pfizer. PM has received honoraria from advisory boards with Pfizer, Astellas, Bayer, Novartis, Janssen, Merck, and MSD, and travel support from Bayer, Merck, and.Pfizer. APi has received research funding from Pfizer and BMS; compensation for speaker fees or advisory boards from Janssen, Astellas, Bayer, MSD, Roche, and Ipsen; compensation for travel expenses from Janssen, MSD, Bayer, and Ipsen. APr reports advisory and consulting fees from Reveal Genomics, AstraZeneca, Daiichi-Sankyo, Roche, Pfizer, Novartis, and Peptomyc, and institutional financial interests from AstraZeneca, Novartis, Roche, and Daiichi Sankyo; stockholder and employee of Reveal Genomics; patents filed PCT/EP2016/080056, PCT/EP2022/086493, PCT/EP2023/060810, EP23382703 and EP23383369. NM receives research grant support from Janssen. ID has participated in compensated advisory boards sponsored by Astellas, Bristol Myers Squibb, Immunomedics, MSD, Roche, Bicycle Therapeutics and Gilead. He has also taken part as an invited speaker in compensated educational activities sponsored by Astellas, Bayer, Bristol Myers Squibb, Jansen, Merck, Pfizer and Roche. Bayer, Astrazeneca and Gilead have covered expenses related to travel, accommodation and registration of medical conferences for ID. He serves as a member of the steering committee of two advanced bladder cancer trials sponsored by GILEAD and is the leading investigator of an investigator-initiated study funded by the same company. His department has received research grants from AstraZeneca and Roche. FXR receives research grant support from Janssen. Clinical Trial EudraCT number: 2017-002246-68 Funding Statement The DUTRENEO study was supported by an unrestricted educational grant by AstraZeneca; Nanostring provided reagents for TIS score. The work was supported, in part, by grants from Fundacion Cientifica de la Asociacion Espanola Contra el Cancer (FXR, DC, AF, and NM, and grant PRYGN223005REAL to FXR). E.P-P., M.S. and M.E. are funded by the AECC project LABAE20038PORT. M.S. is supported by la Caixa Foundation (LCF/BQ/DR22/11950021). E.P-P. is funded by the Spanish Ministry of Science (RYC2019-026415-I MICIU/AEI/10.13039/501100011033), Fundacion FERO-ASEICA (BFERO2002.6), and Generalitat de Catalunya (SGR007) Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All patients signed the informed consent form to be enrolled in the trial, approved by the Ethics Committee of the Hospital Universitario Ramon y Cajal on September 03, 2018 (EudraCT number: 2017-002246-68). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes