Clinical protocol phase II study of tumor infiltrating lymphocytes in advanced tumors with alterations in the SWI/SNF complex: the TILTS study

ABSTRACT

The SWI/SNF complex is a chromatin remodeling complex comprised by several proteins such as SMARCA4 or SMARCB1. Mutations in its components can lead to the development of aggressive rhabdoid tumors such as epithelioid sarcoma, malignant rhabdoid tumor or small cell carcinoma of the ovary hypercalcemic type, among others. These malignancies tend to affect young patients and their prognosis is poor given the lack of effective treatments. Characteristically, these tumors are highly infiltrated by TILs, suggesting that some lymphocytes are recognizing tumor antigens. The use of those TILs as a therapeutic strategy is a promising approach worth exploring. Here, we report the clinical protocol of the TILTS study, a Phase II clinical trial assessing personalized adoptive cell therapy with TILs in patients affected by these tumor types.

Clinical Trial Registration: 2023-504632-17-00 (www.clinicaltrialsregister.eu) (ClinicalTrials.gov).

Plain language summary

Article highlights.

Background & rationale

• There is a group of tumors associated with alterations in the SWI/SNF complex, such as epithelioid sarcoma, malignant rhabdoid tumor or small cell carcinoma of the ovary hypercalcemic type, among others. These tumors usually have rhabdoid features and tend to affect young patients.

• Patients affected by these malignancies have poor prognosis since there are no effective standard treatments.

• Tumors associated with alterations in the SWI/SNF complex are generally infiltrated by a high number of TILs that have been able to recognize a tumor antigen. The use of those TILs as a therapeutic strategy is a promising immunotherapy approach.

The TILTS study

• The TILTS study is a clinical trial designed to assess the activity of adoptive cell therapy with TILs in these tumor types.

• The TILTS study is a prospective, single-arm, multicenter Phase II study that uses personalized TILs treatment in advanced tumors associated with alterations in the SWI/SNF complex.

• The primary end point is ORR per RECIST v1.1 as assessed by investigator. Secondary end points include toxicity evaluation, PFS and OS, among others. In addition, an associated translational study will be conducted in order to better understand the biology of these malignancies and their relationship with the immune system.

1. Background & rationale

1.1. The SWI/SNF complex

The SWItch/sucrose non-fermentable (SWI/SNF) complex has recently become a novel target in cancer treatment since aberrations in genes encoding in its subunits have been found in almost 25% of malignancies. It is an ATP-dependent complex involved in the process of chromatin remodeling which is comprised of a variety of proteins from the SWI and SNF gene families along with additional polypeptides. This complex has ATPase activity and can disrupt histone-DNA interactions in nucleosomes in an ATP-dependent manner. Thus, the SWI/SNF subfamily is crucial for rearranging nucleosomes, making chromatin more accessible therefore allowing gene expression to be regulated [1–3].

1.2. Tumors associated with alterations in the SWI/SNF complex

The role of the SWI/SNF complex in cancer was first suggested with the identification of SMARCB1. Inactivating mutations in SMARCB1 were found in rhabdoid tumors, a rare and aggressive pediatric soft-tissue sarcoma [4,5]. Later, studies on genetically modified mice lacking Smarcb1 showed that these mice developed cancer quickly and with complete penetrance [6]. The importance of SWI/SNF mutations became more evident with cancer genome-sequencing projects. Thus, mutations in ARID1A were described in almost half of ovarian clear-cell carcinomas and ovarian endometrioid carcinomas, making it the most frequently mutated SWI/SNF subunit found [7,8]. PBRM1 mutations were also discovered in 41% of clear-cell renal cell carcinoma cases [9]. Following these findings, numerous other cancers were found to have mutations in genes encoding the SWI/SNF complex. Overall, at least nine SWI/SNF subunits are recurrently mutated across different solid tumors, with these mutations present in nearly 25% of all tumor types [10]. These mutations can occur during tumor evolution in cancers with high genomic instability or as an initial oncogenic event in highly aggressive tumors. Such cancers, often with por prognosis and affecting young patients, include epithelioid sarcoma, malignant rhabdoid tumor, small-cell carcinoma of the ovary, hypercalcemic type (SCCOHT), renal medullary carcinoma, epithelioid malignant peripheral nerve sheath tumor, myoepithelial carcinoma, extra-skeletal myxoid chondrosarcoma, poorly differentiated chordoma, or sinonasal basaloid carcinoma [3]. Unfortunately, these malignancies, which typically present with in advanced stage, have no effective systemic treatments. Moreover, their rarity makes it challenging to conduct tumor-specific clinical trials.

1.3. Rationale for treatment with tumor infiltrating lymphocytes

Tumor infiltrating lymphocytes (TILs) are usually present in high numbers in tumors associated with SWI/SNF aberrations even though these malignancies do not usually show a high tumor mutation burden [11,12]. The biologic reasons for this feature are not clearly understood but might be associated with changes in gene expression due to aberrant chromatin remodeling [3].

Regardless of the underlying cause, the presence of tumor-infiltrating lymphocytes (TILs) suggests that some tumor antigens are being recognized by the immune system, highlighting a potential weakness that can be exploited by immunotherapy. Notably, a study showed that immune checkpoint inhibitors led to tumor regression in up to 70% of mice with Smarcb1-mutant rhabdoid tumors [11]. The underlying mechanism was unique compared with other SWI/SNF mutations, as the loss of SMARCB1 resulted in the expression of endogenous retroviruses, which activated double-stranded RNA-sensing pathways and triggered interferon signaling. Additionally, research involving patients with SMARCA4-mutant SCCOHT found that these tumors responded well to immune checkpoint inhibitors, probably because they have an immune-active microenvironment. even though they have a low number of mutations [13].

Another immunotherapy strategy, TILs treatment, represents a potentially effective treatment for patients with a variety of solid tumors. This treatment modality involves the recovery and ex vivo expansion of autologous antitumor lymphocytes that have infiltrated a patient's tumor. The basic concept of using lymphocytes for the therapy of cancer arose from animal experiments that demonstrated, by histologic analysis, the presence of T-lymphocytes within the microenvironment of most solid tumors and their metastases [14–16]. Subsequent findings have clearly shown a predictive relationship between the frequency and phenotype of TIL in solid tumors (especially CD8⁺ T-cells) and an increased overall survival (OS) and progression-free survival (PFS) in patients with melanoma [17–20], lung cancer [21–24], ovarian cancer [25,26], squamous cell carcinomas [27,28], human epidermal growth factor receptor 2 (HER2)-positive breast cancer [29], basal-like breast cancer [30–34], triple negative breast cancer [35] and colorectal cancer [36–39]. These findings support the development of therapies based on the isolation and expansion of autologous TIL cells as a therapeutic agent against solid tumors. Indeed, the Food and Drug Administration (FDA) has recently approved the TILs therapy lifileucel for advanced melanoma [40]. Moreover, in the first randomized Phase III clinical trial with TILs in solid tumors, an academic TILs therapy has demonstrated superiority in terms of PFS compared with ipilimumab in advanced melanoma [41].

TILs therapy has several theoretical and practical advantages over active immunization and non-specific immune stimulation. The ex vivo environment allows expansion/ production of very high cell numbers in the absence of suppressive factors (e.g., regulatory T-cells which are present in the tumor microenvironment), allowing re-infusion of much higher numbers of tumor-reactive T-cells versus other approaches [42–44]. The TILs product recognizes a wider array of tumor antigens such as mutated tumor neoantigens versus a single target [45–48].

Therefore, the objective of the TILTS study is to develop a personalized adoptive cell therapy using TILs in patients affected by advanced tumors associated with SWI/SNF complex alterations.

1.4. Objectives & end points

The objectives and end points of the TILTS study can be found in Table 1.

Table 1.

Summary of study objectives and end points of the TILTS study.

Study Objectives

Clinical: • Primary   ○ To evaluate the efficacy of autologous TILs as a single therapy in patients affected by unresectable or advanced tumors with alterations in the SWI-SNF complex, as determined by ORR, using the RECIST v1.1, as assessed by investigator. • Secondary   ○ To characterize the benefit in terms of survival as determined by PFS and OS.   ○ To determine the exploratory response end points CRR, DOR and DCR.   ○ To characterize the safety profile of the TILs therapy as a single therapy, as measured by the incidence of AEs according to the NCI-CTCAE v5.0. Translational/exploratory: • To study mechanisms of immunogenicity, antigen recognition, TILs anti-tumor activity and changes in the stool microbiome and specific TCR population during treatment. • To analyze the tumor immune microenvironment in tumor samples.

End points

Primary: • ORR per RECIST v1.1 as assessed by investigator. Secondary: • Toxicity evaluation: nature and frequency of AEs, SAEs, alterations in laboratory test results, vital sign measurements, physical examination findings graded, when applicable, according to NCI-CTCAE v5.0. • CRR per RECIST v1.1 as assessed by investigator. • DOR per RECIST v1.1 as assessed by investigator. • DCR per RECIST v1.1 as assessed by investigator. • PFS per RECIST v1.1 as assessed by investigator. • OS

AE: Adverse event; CRR: Complete response rate; DCR: Disease control rate; DOR: Duration of response; NCI-CTCAE: National Cancer Institute-Common Terminology Criteria for Adverse Events; ORR: Overall response rate; OS: Overall survival; PFS: Progression-free survival; RECIST: Response Evaluation Criteria in Solid Tumor; SAE: Severe adverse event; SWI/SNF: SWItch/sucrose non-fermentable; TCR: T-cell receptor; TIL: Tumor infiltrating lymphocyte.

1.5. Trial design

The TILTS study is a prospective, single-arm, multicenter Phase II study evaluating adoptive cell therapy with TILs as a single therapy in patients with pathologically confirmed diagnosis of advanced solid tumors associated with SWI/SNF aberrations. Patients will be treated at 3 centers in Spain: Catalan Institute of Oncology (ICO), Barcelona, Vall d'Hebron Institute of Oncology (VHIO), Barcelona and Centro Integral Oncológico Clara Campal (HM CIOCC), Madrid

The following study periods will take place:

1.5.1. Pre-screening phase

After signing the pre-screening informed consent form (ICF), a tumor sample will be obtained as the source of the TIL product.

1.5.2. Manufacturing of cell product

Minimum 26 days from tumor resection.

1.5.3. Screening & enrollment phase

Up to 4 weeks (28 days) from signing the ICF. Upon confirmation of study eligibility, patients will be elected for treatment.

1.5.4. Treatment period

Up to 10 days, including nonmyeloablative lymphodepletion (NMA-LD) chemotherapy (5 days), TILs infusion (1 day) followed by interleukin-2 (IL-2) administrations (1 to 4 days).

1.5.5. Assessment period

Begins after TILs infusion on Day 0 and ends upon disease progression, with the start of a new anticancer therapy, partial withdrawal of consent to study assessments, or 10 years, whichever occurs first.

1.5.6. Long-term follow-up period

Begins after the assessment period ends and stops at the end of study (EOS), where EOS can be due to death, patient lost to follow-up, withdrawal of consent, study termination by sponsor, or 10 years from TILs infusion, whichever occurs first.

1.6. Eligibility criteria

Patients are eligible for the TILTS study if they have a pathologically confirmed diagnosis of any of the tumor types stated in Table 2 in the advanced setting.

Table 2.

Tumor types associated with aberrations in the SWI/SNF complex eligible for the TILTS study.

Eligible tumor types
Epithelioid sarcoma
Malignant rhabdoid tumor
Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT)
Renal medullary carcinoma
Epithelioid malignant peripheral nerve sheath tumor (EMPNST)
Myoepithelial carcinoma
Extra-skeletal myxoid chondrosarcoma
Poorly differentiated chordoma
Sinonasal basaloid carcinoma
Other tumors associated with SWI/SNFc mutations

Main inclusion criteria can be found in Table 3 and main exclusion criteria can be found in Table 4.

Table 3.

Summary of main inclusion criteria for the TILTS study.

Inclusion criteria
Pre-screening phase and screening and enrollment phase
Patients must be ≥18 years at the time of consent.
Patients must have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 and an estimated life expectancy of ≥3 months in the opinion of the Investigator.
All patients must have a pathologically confirmed diagnosis of solid tumors associated with SWI/SNFc-mutated monogenic diseases. These solid tumors include, but are not limited to: – Epithelioid sarcoma – Malignant rhabdoid tumor – Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) – Renal medullary carcinoma – Epithelioid malignant peripheral nerve sheath tumor (EMPNST) – Myoepithelial carcinoma – Extra-skeletal myxoid chondrosarcoma – Poorly differentiated chordoma – Sinonasal basaloid carcinoma. – Other tumors associated with SWI/SNFc mutations
Patients must have at least 1 resectable/biopsiable lesion (or aggregate lesions) of a minimum 1.5 cm in diameter for TIL investigational product production. It is encouraged that tumor tissue be obtained from multiple and diverse metastatic lesions, as long as the surgical resection/biopsy do not pose additional risks to the patient. A minimum of 21 days must have elapsed from the last dose of chemotherapy/radiotherapy.
If the lesion considered for resection/biopsy for TIL generation is within a previously irradiated field, the lesion must have demonstrated radiographic progression prior to resection.
Patients must be seronegative for HIV antibody (patients who are HIV seropositive may be less responsive and more susceptible to toxicities related to this experimental treatment since they may have a decreased immune competence).
Patients must be seronegative for active hepatitis B (defined as having a negative hepatitis B surface antigen [HBsAg] test), and seronegative for hepatitis C antibody. Patients with a history of hepatitis B virus (HBV) infection and having a negative HBsAg test and a positive antibody to hepatitis B surface antigen (HBsAg) are eligible. Patients with the hepatitis C antibody test positive are eligible only if tested for the presence of antigen by RT-PCR and be HCV RNA negative
Patients must be seronegative for active CMV, HSV and EBV infections.
Patients must be seronegative for Treponema pallidum antibody.
Only for screening and enrollment phase
Patients must have a measurable disease as defined by RECIST 1.1. Lesions that are partially resected for TIL generation that are still measurable per RECIST may be selected as target lesions
Patients of childbearing potential or those with partners of childbearing potential must be willing to practice an approved method of highly effective birth control during treatment and for 12 months after receiving all protocol related therapy
Patients must have the following hematologic parameters: a. Absolute neutrophil count (ANC) ≥1 × 109/l without the support of filgrastim. b. Hemoglobin ≥9.0 g/dl c. Platelet count ≥100 × 109/l d. Patients must have adequate organ function: – Serum alanine aminotransferase (ALT)/serum glutamic-pyruvic transaminase (GPT) and aspartate aminotransferase (AST)/GOT ≤three-times the upper limit of normal (ULN), patients with liver metastasis ≤five-times ULN; – An estimated creatinine clearance ≥40 ml/min using the Cockcroft Gault formula at Screening; – Total bilirubin ≤2 mg/dl: Patients with Gilbert's Syndrome must have a total bilirubin ≤3 mg/dl. – Serum creatinine <1.5 mg/dl or measured creatinine clearance ≥50 ml/min calculated using the Cockcroft-Gault glomerular filtration rate estimation: (140 – age) × (weight in kg) × (0.85 if female)/72 × (serum creatinine in mg/dl).
Patients must have a washout period from prior anticancer therapy(ies) of a minimum duration, as detailed below prior to the first study treatment (ie, start of NMA-LD): – Chemotherapy: adjuvant, neoadjuvant or definitive chemotherapy/chemoradiation is allowed provided the washout is a minimum of 21 days, prior to the start of treatment. – Prior immunotherapy, checkpoint-targeted therapy, other monoclonal antibodies (mAbs), or vaccines are allowed if disease progression is confirmed prior to or within the washout period of ≥21 days prior to the start of NMA-LD.
Palliative radiation therapy: Prior external beam radiation is allowed at least 2 weeks before TILs infusion provided all radiation-related toxicities are resolved to Grade 1 or baseline, excluding alopecia, skin pigmentation change, or other clinically insignificant events, eg, small area radiation dermatitis or rectal or urinary urgency.
Previous surgical procedure(s) is permitted provided that wound healing has occurred, all complications have resolved and at least 14 days have elapsed (for major operative procedures) prior to the tumor resection
Patients must have recovered from all prior anticancer treatment-related adverse events to Grade ≤1 or baseline except for alopecia or vitiligo.
In the opinion of the Investigator, the patient must be able to complete all study required procedures and can understand the requirements of the study and freely give consent to participate.

Table 4.

Summary of main exclusion criteria for the TILTS study.

Exclusion criteria
Pre-screening phase and screening and enrollment phase
Patients who have a left ventricular ejection fraction (LVEF) <45% or who are New York Heart Association (NYHA) Class II or higher.
Patients who have obstructive or restrictive pulmonary disease and/or have a documented FEV1 (forced expiratory volume in 1 second) ≤50% of predicted normal.
Patients who have received an organ allograft or prior cell transfer therapy that included a nonmyeloablative or myeloablative chemotherapy regimen within the past 20 years.
Patients with symptomatic and/or untreated brain metastases: – Patients with definitively-treated brain metastases will be considered for enrollment if, prior to the start of treatment the patient is clinically stable for ≥2 weeks, there are no new brain lesions via magnetic resonance imaging (MRI) post-treatment and the patient does not require ongoing corticosteroid treatment.
Patients requiring regular treatment with steroids at a dose higher than prednisone 10 mg/day (or equivalent). Use of inhaled, topical steroids and use of systemic physiologic corticosteroid replacement are permitted.
Patients who have an active medical illness(es), which in the opinion of the Investigator, would pose increased risks for study participation, such as systemic infections (e.g., syphilis or any other infection requiring antibiotics), coagulation disorders, or other active major medical illnesses of the cardiovascular, respiratory, or immune systems.
Patients may not have active or prior documented autoimmune or inflammatory disorders (including pneumonitis, inflammatory bowel disease [eg, colitis or Crohn's disease], diverticulitis [with the exception of diverticulosis], systemic lupus erythematosus, sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, hypophysitis, uveitis, etc.]). The following are exceptions to this criterion: – Patients with vitiligo or alopecia; – Patients with hypothyroidism (eg, following Hashimoto syndrome) stable on hormone replacement; – Any chronic skin condition that does not require systemic therapy; or – Patients with celiac disease controlled by diet alone.
Patients who have received a live or attenuated vaccination within 28 days prior to the start of treatment.
Patients who have any form of primary immunodeficiency (such as severe combined immunodeficiency disease [SCID] and acquired immune deficiency syndrome [AIDS]).
Patients with a history of hypersensitivity to any of components of the study drugs and any component of TIL product formulation.
Patients who have had another primary malignancy within the previous 3 years (except for those which do not require treatment or have been curatively treated >1 year ago, and in the judgment of the Investigator, does not pose a significant risk of recurrence).
Patients who are pregnant or breastfeeding.

1.7. Interventions

The TILs therapy is comprised of the following steps:

• ▪Tumor resection or tumor biopsy to provide the autologous tissue that serves as the source of the TILs cellular product.
• ▪TILs investigational product manufacturing at a central Good Manufacturing Practice (GMP) facility located at the Blood and Tissue Bank (BST), Barcelona, Spain. TILs product is composed of live, autologous, tumor-derived T-lymphocytes, expanded, adjusted to the dose range of 5 × 10⁸ – 1.1 × 10¹¹ viable cells and resuspended in conditioning solution for iv infusion.

• Tumor resection or tumor biopsy to provide the autologous tissue that serves as the source of the TILs cellular product.

• TILs investigational product manufacturing at a central Good Manufacturing Practice (GMP) facility located at the Blood and Tissue Bank (BST), Barcelona, Spain. TILs product is composed of live, autologous, tumor-derived T-lymphocytes, expanded, adjusted to the dose range of 5 × 10⁸ – 1.1 × 10¹¹ viable cells and resuspended in conditioning solution for iv infusion.

• Patients will undergo baseline imaging during the screening period before the initiation of NMA-LD chemotherapy regimen.

• A 5-day NMA-LD chemotherapy preconditioning regimen consisting of 2 days of iv cyclophosphamide (60 mg/kg) with mesna (per site standard of care) on day -5 and day -4 and 5 days of iv fludarabine (25 mg/m2: day -5 through day -1).

• Infusion of TILs (day 0).

• Following TILs infusion, up to 6 iv IL-2 600,000 IU/kg doses maximum will be administered. IL-2 administrations may begin as soon as 3 h after, but no later than 24 h after completion of the TIL infusion.

Figure 1 depicts a summary of the TILTS study interventions.

Figure 1.

Schema of interventions in the TILTS study.

EOS: End of study; EOT: End of treatment; IL-2: Interleukin-2; NMA-LD: Nonmyeloablative lymphodepletion; TIL: Tumor infiltrating lymphocyte.

1.8. Sample size & statistical considerations

The TILTS study is planned to include at least 11 patients to show an increase from 5% overall response rate (ORR) that would be expected with standard treatment to 35% with TILs therapy in the intention to treat (ITT) population, by using a one-sided binomial test with type I error 5%, power 80% and assuming 10% attrition rate. Enrolled patients who did not receive TILs infusion will be replaced.

The statistical analysis is based on use of descriptive. Continuous data will be summarized as the number of patients with no missing data, mean, standard deviation, median, minimum and maximum values. Categorical data will be summarized as counts and their related percentages, where applicable.

1.9. Ethics & dissemination

The TILTS study has been approved by the European Medicines Agency (EMA) and has been granted the EUCT number 2023-504632-17-00. The study is being conducted in full compliance with the principles of the “Declaration of Helsinki” (as amended in Tokyo, Venice, Hong Kong and South Africa), International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines and with the local laws and regulations. All Investigators will ensure adherence to ICH guidelines for Good Clinical Practice (GCP) and Clinical Safety Data Management. All subjects give their written informed consent for inclusion before they participate in the study. The protocol was approved by a reference ethics committee (CEIm Hospital Universitari de Bellvitge, Barcelona, Spain).

The Spanish Group for Research on Sarcomas (GEIS), the Spanish Group for Investigation in Ovarian Cancer (GEICO) and the Spanish Group for Rare Tumors (GETHI) will disseminate the clinical study by publishing periodical newsletters in order to warrant the expected recruitment.

2. Conclusion

Patients affected by tumors associated with alterations in the SWI/SNF complex usually have very poor prognosis due to the lack of effective treatments. Moreover, these malignancies tend to affect young patients so it is necessary to find novel therapeutic strategies in order to improve their survival.

This group of tumors are generally infiltrated by a high number of TILs, indicating that an immune response has been triggered. Therefore, immunotherapy might be an effective treatment strategy. Indeed, some preliminary reports using immune-checkpoint inhibition in these malignancies have shown promising results. Another immunotherapy approach, the use of TILs as a treatment, is a therapeutic strategy worth exploring.

Thus, the TILTS study aims to assess the activity of a personalized TILs treatment in patients affected by advanced tumors associated with alterations in the SWI/SNF complex. The results of this clinical trial will help to achieve the much-needed goal of improving these patients' prognosis.

Funding Statement

This study has been funded by Instituto de Salud Carlos III through the project ICI21/00110. Funded by European Union – NextGenerationEU. We thank CERCA Programme/Generalitat de Catalunya for institutional support. This research has been funded by the Comprehensive Program of Cancer Immunotherapy & Immunology II (CAIMI-II) supported by the BBVA Foundation (grant 53/2021).

Author contributions

J Martin-Liberal, E Garralda, J García-Donas, JJ Soto-Castillo, C Codony, S Martin-Lluesma, S Muñoz, V Galvao, J Lostes, M Rotxes, A Gros and JM Piulats contributed to the design of the study and writing of the protocol. A Muñoz, R Moreno, R Alemany, A Gros and JM Piulats contributed to the analysis of study samples at the central laboratory. C Prat-Vidal, J Palomero and A Gros contributed to the manufacturing of the cell product. S Muñoz is the medical monitor of the study. J Martin-Liberal, E Garralda, J García-Donas and XG del Muro contributed to the identification and enrolment of patients in the study. A Mussetti and A Sureda contributed to the treatment of patients. J Martin-Liberal wrote this manuscript. All authors read, reviewed and approved the protocol and the final manuscript.

Financial disclosure

This study has been funded by Instituto de Salud Carlos III through the project ICI21/00110. Funded by European Union – NextGenerationEU. We thank CERCA Programme/Generalitat de Catalunya for institutional support. This research has been funded by the Comprehensive Program of Cancer Immunotherapy & Immunology II (CAIMI-II) supported by the BBVA Foundation (grant 53/2021). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Competing interests disclosure

J Martin-Liberal has received lecture fees from Astellas, Bristol-Myers Squibb, MSD, Novartis, Pierre Fabre, Pfizer, Roche, Sanofi; advisory fees from BMS, Highlight Therapeutics, Novartis, Pierre Fabre, Roche, Sanofi; and travel grants from Bristol-Myers Squibb, Merck, MSD, Novartis, Pierre Fabre, Pfizer, Roche, Ipsen. E Garralda has received grants from Novartis, Roche, Thermo Fisher, AstraZeneca, Taiho, BeiGene, Janssen; consulting fees from Roche, Ellipses Pharma, Boehringer Ingelheim, Janssen Global Services, Seattle Genetics, Thermo Fisher, MabDiscovery, Anaveon, F-Star Therapeutics, Hengrui, Sanofi, Incyte, Medscape; lecture fees from MSD, Roche, Thermo Fisher, Novartis, SeaGen; and has stocks in 1TRIALSP. J García-Donas has received advisory fees from Bristol-Myers Squibb, Ipsen, Janssen, MSD, Pfizer, Merck, Astra Zeneca, Astellas, Gilead, Roche, Incyte; research grants from Pfizer, Astellas, Gilead, Merck, GSK, Bristol-Myers Squibb; and travel grants from Ipsen. JJ Soto-Castillo has received travel and accommodations grants from Pfizer, Eisai and Seagen. A Mussetti has received consulting fees from Takeda, BMS, Merck, Jazz Pharma; and research funding from Gilead/Kite. XG del Muro has received lecture fees from Astellas, Pfizer, Eisai, Recordati; advisory fees from MSD, BMS, Pfizer, Ipsen, Roche, Pharmamar, GSK, Merck, Eisai, Deciphera, Recordati, Astellas; and travel grants from Merck, Pfizer, Roche. A Sureda has received honoraria from AbbVie, Alexion, Amgen, BMS/Celgene, GenMab, Gilead, Janssen, Jazz Pharmaceuticals, Kite, MSD, Novartis, Pierre Fabre, Regeneron, Roche, Sanofi, Takeda; speaker fees from Takeda; consulting fees from AbbVie, BMS/Celgene, GenMab, Gilead, Incyte, Janssen, Novartis, Pierre Fabre, Sanofi, Takeda; and research grants from Takeda. R Alemany has received honoraria and research funding from Theriva Biologics. A Gros is a member of the scientific advisory board of Achilles Therapeutics, SingulaBIO, RootPath and BioNTech; consults for PACT Pharma, Instil Bio; and is co-inventor of patents licensed and with royalties E-059-2013/0 E-085-2013/0, E-149-2015/0. JM Piulats has received advisory fees from Advanced Accelerator Applications/Novartis, Astellas, AstraZeneca, Bayer, BeiGene, Bristol-Myers Squibb, Clovis, Janssen, MSD, Pfizer, Roche, Sanofi; research grants from BeiGene, Bristol-Myers Squibb, Janssen, Merck, Mirati, MSD, Pfier; and travel grants from AstraZeneca, Pfizer.

The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research

The TILTS study has been approved by the European Medicines Agency (EMA) and has been granted the EUCT number 2023-504632-17-00. The study is being conducted in full compliance with the principles of the “Declaration of Helsinki” (as amended in Tokyo, Venice, Hong Kong and South Africa), International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines and with the local laws and regulations. All Investigators will ensure adherence to ICH guidelines for Good Clinical Practice (GCP) and Clinical Safety Data Management. All subjects give their informed consent for inclusion before they participate in the study. The protocol was approved by a reference ethics committee (CEIm Hospital Universitari de Bellvitge, Barcelona, Spain).