Oncogene-addicted metastatic non-small-cell lung cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

Spatial Heterogeneity of PD-L1 Expression as a Biomarker for Third-Generation EGFR-TKI Response in Advanced EGFR-Mutant NSCLC

The association between the spatial heterogeneity of programmed cell death ligand 1 (PD-L1) expression and the efficacy of third-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in EGFR-mutant non-small cell lung cancer (NSCLC) remains elusive. This retrospective study analyzed data from 4171 NSCLC patients with EGFR-sensitive mutations treated at Shanghai Chest Hospital from August 2019 to September 2023. Among them, 182 patients receiving third-generation EGFR-TKIs monotherapy as a first-line treatment were enrolled. Patients were categorized by biopsy sites into primary lung lesions (n = 112) and metastatic lymph nodes (n = 70). PD-L1 expression was stratified based on tumor cell proportion score (TPS): < 1%, 1%-49%, and ≥ 50%. The median progression-free survival (PFS) for the entire cohort was 18.33 months. In the PD-L1 TPS group, PFS was 18.87 months for TPS < 1%, 17.6 months for TPS 1%-49%, and 13.6 months for TPS ≥ 50%, with significant differences across groups (p = 0.026). Moreover, multivariate analysis identified smoking history [HR = 1.653, 95% CI (1.132-2.414), p = 0.009] and TPS ≥ 50% [HR = 2.069, 95% CI (1.183-3.618), p = 0.011] as independent risk factors. In primary lesions, the median PFS was 21.93 months for TPS < 1%, 18.57 months for TPS 1%-49%, and 10.17 months for TPS ≥ 50%, with significant differences (p < 0.001). However, PD-L1 expression in metastatic lymph nodes was not associated with PFS (p = 0.973). In advanced EGFR-mutant NSCLC, high PD-L1 expression may suggest reduced efficacy of third-generation EGFR-TKIs. The spatial heterogeneity of PD-L1 expression could influence its predictive accuracy for third-generation EGFR-TKI efficacy.

BRAF in non-small cell lung cancer: From molecular mechanisms to clinical practice

V-Raf murine sarcoma viral oncogene homolog B (BRAF) mutations are found in up to 4% of patients with non-small cell lung cancer (NSCLC). Approximately 2% of advanced NSCLC cases harbor a BRAF V600E (class I) mutation. Because targeted therapies inhibiting BRAF (e.g., dabrafenib and encorafenib) and MEK (trametinib and binimetinib) are associated with improved outcomes as first- or second-line treatment for BRAF V600E-mutant NSCLC, both European Society for Medical Oncology and National Comprehensive Cancer Network guidelines recommend testing for the BRAF V600E oncogenic driver at the time of diagnosis. In recent years, the treatment landscape of this molecular subgroup has seen great development. Different therapeutic strategies including anti-programmed death ligand 1 antibodies and kinase inhibitors have been assessed thus far, with novel agents (e.g., pan-BRAF inhibitors) and therapeutic associations underway in preclinical and clinical trials. This review describes the current understanding of the BRAF clinicopathologic role in NSCLC, with a special focus on published trials assessing currently approved therapies. Mechanisms of drug resistance and future perspectives on the therapeutic approach of BRAF-deregulated NSCLC are also summarized.

Update advances in anaplastic lymphoma kinase-positive non-small cell lung cancer treatment

Lung cancer is the leading cause of cancer death worldwide. However, since the discovery and development of targeted therapies and immune checkpoint inhibitors, it has been a dramatically improved in survival outcomes and quality of life. Anaplastic lymphoma kinase (ALK) rearrangements occur in approximately 5% of patients with advanced non-small cell lung cancer (NSCLC), and the introduction of ALK tyrosine kinase inhibitors (TKIs) has changed the treatment paradigm. Although head-to-head randomized controlled trials for late generation inhibitors are lacking, the authors will review the current available options, treatments efficacy, safety profiles, ALK mechanisms of resistance, as well as new promising treatments in this field.

Novel strategies for rare oncogenic drivers in non-small-cell lung cancer: An update from the 2024 Annual ESMO meeting

Across the landscape of oncogene-addicted non-small-cell lung cancer (NSCLC), various tyrosine kinase inhibitors (TKIs) have been introduced in the last twenty years. During the 2024 Annual ESMO meeting new therapeutic options were presented for EGFR exon 20 insertion mutation, ALK fusion and ROS1 fusion positive advanced stage NSCLC. For EGFR exon 20 insertion mutation positive NSCLC, results from REZILIENT-1, a single arm phase II study with zipalertinib, were presented, showing an objective response rate (ORR) of 50% in patients that were pretreated with amivantamab, and 25% in patients pretreated with amivantamab and an EGFR exon 20 insertion-directed TKI. The vast majority of these patients also received platinum-doublet chemotherapy. For ALK, results from ALKOVE-1, a single arm phase I/II study with NVL-655, a next generation ALK TKI, were presented. The ORR was 35 % in patients pretreated with ≥ 2 ALK TKIs including lorlatinib and 57 % in patients pretreated with ≥ 1 ALK TKI, excluding lorlatinib. The median number of prior anticancer therapies was 3. Intracranial responses were seen in lorlatinib naïve- and lorlatinib pretreated patients and toxicity was manageable. In addition, results of the first-line randomized phase III INSPIRE study were presented, in which iruplinalkib, an ALK and ROS1 selective TKI, is being evaluated versus crizotinib. Iruplinalkib showed a superior median PFS (36.8 versus 14.55 months for crizotinib), but no difference in 36-month overall survival (OS) rate. Finally, results from ARROS-1, a single arm phase I/II study with zidesamtinib, a ROS1 selective and TRK-sparing TKI, were presented. An ORR of 73% was obtained in patients that were pretreated with crizotinib and an ORR of 38% in patients pretreated with repotrectinib. In this review, we will discuss the relevant study results presented at ESMO 2024 for these three genomic drivers and hypothesize on their respective place in the sequence of treatment options.

Non-Small Cell Lung Cancer Patients with Skip-N2 Metastases Have Similar Survival to N1 Patients-A Multicenter Analysis

Introduction: Nodal involvement is one of the most important prognostic factors in NSCLC. Skip-N2 metastasis (N0N2), which is N2 metastasis in the absence of N1 metastasis, occurs in approximately 20-30% of patients. According to the International Association for the Study of Lung Cancer, N1 and N0N2 patients may have comparable long-term survival, considering their similar tumor stages. However, this conclusion remains controversial. Therefore, we carried out this multicenter study to examine the long-term survival and disease-free interval (DFI) of N0N2- and N1 patients. Methods: One-, three-, and five-year survival rates were measured. Kaplan-Meier curves and a Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. Results: Between January 2010 and December 2020, 273 N0N2 and N1 patients were included in our analysis. Of those patients, 77 showed N0N2 and 196 N1. Baseline characteristics did not differ significantly between groups. Between N0N2 and N1 patients, there were no significant differences in one- (p = 0.67), three- (p = 0.20), and five-year (p = 0.27) survival. Furthermore, DFI did not differ between groups (p = 0.45). Conclusions: Our findings indicate that N0N2 patients have a prognosis comparable to that of patients with N1 disease. These results indicate that patients with N0N2 have a similar prognosis to N1 patients. N2-NSCLC is heterogeneous and would benefit from a more precise subdivision and differential treatment in the upcoming UICC 9 classification. The following question remains: are we overtreating N0N2 patients or undertreating N1 patients?

Prognostic significance of total metabolic tumor volume on baseline 18F-FDG PET/CT in patients with lung adenocarcinoma: further stratification of the ninth edition of TNM staging subgroups

BACKGROUND

This study aimed to investigate the prognostic value of baseline total metabolic tumor volume (TMTV) on 18F-fluorodeoxyglucose positron emission tomography/computed tomography and its potential for further stratification within the ninth tumor-node-metastasis (TNM) staging system in patients with lung adenocarcinoma (LUAD).

METHODS

A cohort of 384 patients with LUAD who had undergone pretreatment PET/CT were included in this retrospective study. The optimal cutoff value for TMTV was determined through analysis of time-dependent receiver operating characteristic curves. The analysis of overall survival (OS) was conducted utilizing Kaplan-Meier curves. Predictive capacity was evaluated using the C statistic.

RESULTS

The optimal cutoff value for TMTV was 40.13 ml. The survival rates of patients varied significantly across stages I (n = 164), II (n = 37), III (n = 46), and IV (n = 137); however, there was no statistically significant difference between stages II and III (P = 0.440). In stages II-IV, the 2-year OS rates for patients with TMTV less than 40.13 ml were significantly higher at 81.7 and 86.7%, respectively, compared with patients with TMTV greater than equal to 40.13 ml who had rates of only 56.5 and 42.5%. No patients with stage I presented TMTV greater than or equal to 40.13 ml, and the 2-year OS rate was 98.3%. The C index did not reveal a significant difference between TNM and TMTV in their predictive ability for OS (0.83 vs. 0.85, P = 0.159).

CONCLUSION

The TNM staging system demonstrates robust prognostic utility in patients with LUAD, while the incorporation of baseline TMTV may offer additional risk stratification within distinct TNM stages.

Emerging molecular testing paradigms in non-small cell lung cancer management-current perspectives and recommendations

Advances in molecular testing and precision oncology have transformed the clinical management of lung cancer, especially non-small cell lung cancer, enhancing diagnosis, treatment, and outcomes. Practical guidelines offer insights into selecting appropriate biomarkers and assays, emphasizing the importance of comprehensive testing. However, real-world data reveal the underutilization of biomarker testing and consequently targeted therapies. Molecular testing often occurs late in diagnosis or not at all in clinical practice, leading to delayed or inadequate treatment. Enhancing precision requires adherence to best practices by all health care professionals involved, which can ultimately improve lung cancer patient outcomes. The future of precision oncology for lung cancer will likely involve a more personalized approach, starting increasingly from earlier disease settings, with novel and more complex targeted therapies, immunotherapies, and combination regimens, and relying on liquid biopsies, muti-detection advanced genomic technologies and data integration, with artificial intelligence as a central orchestrator. This review presents the currently known actionable mutations in lung cancer and new upcoming ones that are likely to enter clinical practice soon and provides an overview of established and emerging concepts in testing methodologies. Challenges are discussed and best practice recommendations are made that are relevant today, will continue to be relevant in the future, and are likely to be relevant for other cancer types too.

Current Biomarkers in Non-Small Cell Lung Cancer-The Molecular Pathologist's Perspective

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related mortality worldwide. Advances in tissue-based biomarkers have significantly enhanced diagnostic and therapeutic approaches in NSCLC, enabling precision medicine strategies. This review provides a comprehensive analysis of the molecular pathologist's practical approach to assessing NSCLC biomarkers across various specimen types (liquid biopsy, broncho-alveolar lavage, transbronchial biopsy/endobronchial ultrasound-guided biopsy, and surgical specimen), including challenges such as biological heterogeneity and preanalytical variability. We discuss the role of programmed death ligand 1 (PD-L1) immunohistochemistry in predicting immunotherapy response, the practice of histopathological tumor regression grading after neoadjuvant chemoimmunotherapy, and the application of DNA- and RNA-based techniques for detecting actionable molecular alterations. Finally, we emphasize the critical need for quality management to ensure the reliability and reproducibility of biomarker testing in NSCLC.

Targeted therapy for non-small cell lung cancer (NSCLC) in a real-world setting: A single practice experience

Targeted treatment of non-small cell lung cancer (NSCLC) with driver aberrations has drastically improved the outcome of a subset of patients. However, for successful adaptation in the clinical routine, many stakeholders are involved, like comprehensive cancer centers, molecular pathology, peripheral hospitals, and oncology practices. Here, we present a single center experience in personalized treatment of lung cancer in Germany. Patients with advanced NSCLC and the need for systemic treatment after identification of a targetable driver mutation have been included in this analysis. Detection of the mutations was performed within a diagnostical network. Treatment was chosen depending on the respective driver mutation. We identified 58 patients (26 male, 32 female) with treatment relevant driver mutations: 33 patients (56.9 %) had an EGFR mutation, nine patients (15.5 %) presented with ALK translocation, five patients (8.6 %) were detected to have BRAF mutations, four had ROS1 translocations (6.9 %) and 8 patients had MET mutations (13.8 % each). In one patient, concomitant BRAF and MET amplifications were detected. 52 patients received targeted therapy. The median overall survival was 35.5 months (95 % CI, 18.0-52.9 months). 32 patients (64 %) received subsequent treatment after initiation of targeted therapy first-line. Our single-center experience demonstrates that advances in the field of targeted NSCLC therapy are quickly incorporated into clinical routine in Germany. Noteworthy, no new safety information was found.

EGFR testing practices, treatment choice and clinical outcomes in advanced NSCLC in a real-world setting: A retrospective analysis of a US-based electronic health records database

OBJECTIVES

Guidelines recommend epidermal growth factor receptor (EGFR) mutation testing for patients with advanced non-small cell lung cancer (NSCLC) and initiation of first-line EGFR tyrosine kinase inhibitors (EGFR-TKIs) for EGFR mutation-positive (EGFRm) NSCLC. We analyzed a nationwide electronic health record-derived de-identified database to describe EGFR testing practices, treatment choice, and outcomes in patients from the United States (US) with advanced NSCLC.

MATERIALS AND METHODS

Adults diagnosed with stage IIIB-IV NSCLC January 2015-January 2020, who received first-line treatment from a network of ∼280 US cancer clinics were included. Demographics/characteristics, EGFR status, time from advanced diagnosis to EGFR test result, first-line treatment, time from treatment initiation to discontinuation/death (TTD), next treatment/death (TTNTD), and overall survival (OS) were extracted.

RESULTS

12,577/16,309 (77 %) eligible patients had an EGFR test recorded; 1,914/12,577 (15 %) patients had EGFRm NSCLC. Of 1,778 patients with confirmed EGFRm NSCLC before first-line treatment, 75 % received first-line EGFR-TKIs, 11 % chemotherapy, 9 % immunotherapy, and 4 % other treatment. Of 136 patients with an EGFRm result after initiating first-line treatment, 13 % received EGFR-TKIs, 50 % chemotherapy, 19 % immunotherapy, and 18 % other treatment in first-line. Among patients with EGFRm NSCLC, median time from advanced diagnosis to EGFR test result was shorter in patients who received first-line EGFR-TKIs versus first-line chemotherapy/immunotherapy/other treatment. Patients treated with first-line EGFR-TKIs had significantly improved TTD/TTNTD versus those who received first-line chemotherapy/immunotherapy/other treatment (p < 0.001). OS was significantly longer in patients receiving treatment ≥21 versus <21 days after index (p < 0.001).

CONCLUSIONS

Nearly one-quarter of patients with advanced NSCLC in a US health network were not tested for EGFR mutations. Of patients who received a EGFRm result after initiating first-line treatment, 13 % received first-line EGFR-TKIs. These real-world data support the need to improve EGFR testing implementation and time to result to optimize first-line treatment for advanced NSCLC.

Clinical Utility of Combined Tissue and Plasma Next-Generation Sequencing in Patients With Advanced, Treatment-Naïve NSCLC

Introduction

Tissue and plasma-based next-generation sequencing (NGS) have complementary roles in patients with advanced NSCLC. Nevertheless, whether there is any added clinical value in combining both methods in the treatment of naïve patients remains unclear.

Methods

We retrospectively collected clinical and genomic data from 275 patients with treatment-naïve advanced NSCLC who had undergone plasma-based NGS at diagnosis in our institution. We analyzed patient data in two separate cohorts, each assessed with a different plasma-based NGS method: cohort 1 (n = 127, Guardant360), and cohort 2 (n = 148, FoundationACT/FoundationOne Liquid CDx). Ninety-five patients (75%) in cohort 1 and 108 patients (73%) in cohort 2 underwent concurrent amplicon-based tissue NGS testing locally.

Results

Forty-three patients in cohort 1 (34%) and 49 patients in cohort 2 (33%) harbored European Society for Medical Oncology Scale for Clinical Actionability of Molecular Targets (ESCAT) I or II targetable driver alterations. The addition of orthogonal biopsy (tissue to liquid, or liquid to tissue) offered no relevant clinical value in cases with ESCAT I or II targetable drivers already detected by one method. In contrast, adding orthogonal biopsy incremented the detection of ESCAT I or II targetable drivers not only in cases with uninformative testing (undetectable circulating tumor DNA, unavailable/inadequate tissue) but also in about 5% of the patients with seemingly informative but driver undetected molecular results. The prevalence of ESCAT I or II targetable drivers in plasma was significantly higher in patients with adenocarcinoma, 20 pack-year or less smoking history, and abdominal metastases.

Conclusions

Our study suggests that the addition of sequential orthogonal biopsy should be considered whenever an ESCAT I or II targetable driver has not been detected by the initial method, including cases with seemingly informative molecular analysis.

Artificial intelligence-based biomarkers for treatment decisions in oncology

The development of new therapeutic strategies such as immune checkpoint inhibitors (ICIs) and targeted therapies has increased the complexity of the treatment landscape for solid tumors. At the current rate of annual FDA approvals, the potential treatment options could increase by tenfold over the next 5 years. The cost of personalized medicine technologies limits its accessibility, thus increasing socioeconomic disparities in the treated population. In this review we describe artificial intelligence (AI)-based solutions - including deep learning (DL) methods for routine medical imaging and large language models (LLMs) for electronic health records (EHRs) - to support cancer treatment decisions with cost-effective biomarkers. We address the current limitations of these technologies and propose the next steps towards their adoption in routine clinical practice.

Advancing real-world research in thoracic malignancies: learnings from the international I-O Optimise initiative

In recent years, the thoracic malignancies treatment landscape has become more complex with the emergence of novel targeted and immunotherapy-based treatments. Although beneficial to patients and physicians, this fast-paced therapeutic evolution has increased the complexity of clinical decision-making and amplified the importance of real-world evidence to support data from randomized controlled trials. The international I-O Optimise initiative was established in 2016 to provide real-world insights into the thoracic malignancies treatment landscape, and has since collaborated with 14 data sources across Europe and Canada, allowing access to data from ~ 500,000 patients with non-small-cell lung cancer, small-cell lung cancer, and malignant pleural mesothelioma. This article reviews pertinent I-O Optimise research, with discussion of the methodological/data-related learnings and expectations for future insights.

[Molecular characterization of lung cancers: up-date and recommendations]

Molecular testing of non-small cell lung cancers has become mandatory at all stages of the disease. National and international recommendations for molecular testing are up-dated regularly. In this review, we will summarize diagnostic approaches focusing on targetable oncogenic alterations (mutations, gene rearrangements) and we will indicate the limits currently associated with sample types and sequencing technologies. Biomarkers that have not showed routine clinical utility will not be presented here.

A Podcast Discussion on the Intracranial Efficacy of Antibody-Drug Conjugates in Patients with EGFR-Mutated NSCLC with Brain Metastases

The incidence of brain metastases is higher in patients with non-small cell lung cancer (NSCLC) than in patients with most other cancers, and the development of brain metastases is associated with poor prognosis. The objective of the podcast is to provide information about current and future treatments for brain metastases that develop in patients with EGFR-mutated NSCLC. The panel discusses surveillance and management of patients with brain metastases, different types of currently used treatments, and recent data on the intracranial efficacy of antibody-drug conjugates (ADCs). The panel also discusses current and future studies of ADCs in patients with EGFR-mutated NSCLC with brain metastases. This podcast discussion, among four oncologists (two thoracic oncologists, one radiation oncologist, and one neurologist/neuro-oncologist), is for healthcare professionals (HCPs) at community practices and research institutions.

Debate on first-line treatment strategies in advanced non-small cell lung cancer with EGFR mutation: An expert panel meeting by the Italian Association of Thoracic Oncology (AIOT)

BACKGROUND

The front-line treatment options and regulatory approval scenario for epidermal growth factor receptor (EGFR) mutation positive metastatic non-small cell lung cancer (NSCLC) have rapidly evolved in the recent months, with newly presented positive trial results of novel compounds and combination strategies in the setting of common activating mutations, uncommon mutations, and exon 20 insertions. In this context, international lively debate is emerging on how to choose among the available regimens, based on efficacy and safety results.

METHODS

A virtual International Expert Panel was held in July 2024 to review data on front-line regimens in patients with NSCLC harboring EGFR mutations, including common, uncommon and exon 20 insertions. The panel discussed available evidence, and reached common considerations for clinical practice and clinical research.

RESULTS

In the setting of EGFR common activating mutations, all panelists agreed that single agent osimertinib, the combination of osimertinib with platinum-pemetrexed, and the combination of amivantamab and lazertinib, are first-line treatment options. Overall, panelists defined characteristics of patients in which combination treatments should be avoided. Subsequent treatment strategies at disease progression were discussed according to the different front-line options. With regards to uncommon EGFR mutations, panelists agreed that afatinib remains the only drug with phase 3 results available, and that afatinib and osimertinib are the preferred first-line options. In EGFR exon20 insertion positive disease, the combination of carboplatin, pemetrexed and amivantamab has been identified as the preferred front-line treatment, with second-line amivantamab to be used in the second-line setting whenever not available in front-line. The panelists defined priorities in clinical research, with high priority attributed to investigating resistance mechanisms, novel generation of tyrosine kinase inhibitors, and selection biomarkers.

CONCLUSIONS

Different toxicity profiles and sequential strategies were considered, together with efficacy results, to reach common considerations for the front-line treatment strategies in EGFR mutant NSCLC, however clinical research should be prioritized to identify further selection features.

Investigating osimertinib plus chemotherapy in EGFR-mutated advanced non-small cell lung cancer

INTRODUCTION

Worldwide, 15-40% of advanced-stage non-small cell lung cancers (NSCLCs) have an activating EGFR mutation, treatable with tyrosine-kinase inhibitors (TKIs) such as osimertinib, recommended as front-line therapy. Despite the efficacy of first-line osimertinib, most patients will experience disease progression. Therefore, combining it with chemotherapy has become an area of interest.

AREAS COVERED

Osimertinib is a third-generation EGFR-TKI that has extended survival in NSCLC patients with EGFR mutation. However, resistance eventually leads to treatment failure. This has driven the advancement of strategies to overcome resistance to osimertinib. In this setting, the FLAURA2 trial yielded positive results by combining osimertinib with chemotherapy. Additionally, a range of other approaches, including the use of bispecific antibodies and antibody-drug conjugates alongside third-generation EGFR-TKIs or chemotherapy, support the development of novel therapeutic combinations, some of which have already been approved for EGFR-mutated advanced NSCLC.

EXPERT OPINION

Next to osimertinib monotherapy, expanded upfront treatment options for patients with EGFR-mutated advanced NSCLC require patient selection considering disease extent, toxicity and tolerability, dosing schedule and what the patient can expect through shared decision-making. Further studies are needed to identify the patients who will benefit the most from combination therapies and to sequence the new drugs into the treatment algorithm.

Efficacy of amivantamab, a bi-specific antibody targeting EGFR and MET, in ALK-rearranged non-small-cell lung cancer cell lines

BACKGROUND

Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) are highly effective in treating ALK-rearranged non-small-cell lung cancer (NSCLC). However, at least 40% of patients develop acquired resistance during treatment. Adaptive or acquired resistance to ALK TKIs could be mediated through epidermal growth factor receptor (EGFR) and mesenchymal-epithelial transition factor (MET) signaling. Sixteen percent of acquired resistance cases are linked to bypass signaling.

METHODS

In this study, we evaluated the effects of amivantamab, a bi-specific antibody targeting both EGFR and MET, on ALK-rearranged NSCLC cells. We investigated the effect of amivantamab on the ALK-rearranged NSCLC cell lines H3122, ABC-19, and ABC-11.

RESULTS

Combining alectinib with amivantamab resulted in greater inhibition of cell growth inhibition in H3122 and ABC-19 cells compared to alectinib alone, but not in ABC-11 cells. EGFR TKI erlotinib showed similar efficacy in H3122 and ABC-19 cells, whereas MET TKI tepotinib was ineffective in both, suggesting that the efficacy of amivantamab is through EGFR inhibition. Unlike H3122 and ABC-19 cells, ABC-11 cells were resistant to EGFR/MET signaling inhibition. Interestingly, amivantamab enhanced alectinib efficacy against ABC-11 cells in the presence of peripheral blood mononuclear cells (PBMCs), despite showing no effect alone without PBMCs, suggesting action through non-signal inhibitory mechanisms. Finally, we treated alectinib-resistant cellswith alectinib, with or without amivantamab, and found that amivantamab restored the sensitivity of these cells to alectinib.

CONCLUSION

The bi-specific antibody amivantamab, which targets EGFR and MET, enhanced the efficacy of alectinib through both signal and non-signal inhibitory mechanisms in ALK-rearranged NSCLC cells.

Circulating tumour DNA in early stage and locally advanced NSCLC: ready for clinical implementation?

Circulating tumour DNA (ctDNA) can be released by cancer cells into biological fluids through apoptosis, necrosis or active release. In patients with non-small-cell lung cancer (NSCLC), ctDNA levels correlate with clinical and pathological factors, including histology, tumour size and proliferative status. Currently, ctDNA analysis is recommended for molecular profiling in patients with advanced-stage NSCLC. In this Review, we summarize the increasing evidence suggesting that ctDNA has potential clinical applications in the management of patients with early stage and locally advanced NSCLC. In those with early stage NSCLC, detection of ctDNA before and/or after surgery is associated with a greater risk of disease recurrence. Longitudinal monitoring after surgery can further increase the prognostic value of ctDNA testing and enables detection of disease recurrence earlier than the assessment of clinical or radiological progression. In patients with locally advanced NSCLC, the detection of ctDNA after chemoradiotherapy is also associated with a greater risk of disease progression. Owing to the limited number of patients enrolled and the different technologies used for ctDNA testing in most of the clinical studies performed thus far, their results are not sufficient to currently support the routine clinical use of ctDNA monitoring in patients with early stage or locally advanced NSCLC. Therefore, we discuss the need for interventional studies to provide evidence for implementing ctDNA testing in this setting.

The Society of Thoracic Surgeons (STS) Clinical Practice Guideline on Surgical Management of Oligometastatic Non-small Cell Lung Cancer

BACKGROUND

The use of local consolidative therapy (LCT) in patients with oligometastatic non-small cell lung cancer (NSCLC) is rapidly evolving, with a preponderance of data supporting the benefits of such therapeutic approaches incorporating pulmonary resection for appropriately selected candidates. However, practices vary widely institutionally and regionally, and evidence-based guidelines are lacking.

METHODS

The Society of Thoracic Surgeons assembled a panel of thoracic surgical oncologists to evaluate and synthesize the available evidence regarding the role of pulmonary resection as LCT. Clinical and research questions of interest were identified, and a complete literature review was conducted. Best practice guidelines were developed accordingly.

RESULTS

The panel identified 7 areas of controversy, and data were assimilated to support the best recommended practices related to these clinical issues. Ultimately, a number of issues in this realm were found to have a high level of evidence to support the role for surgical therapy in patients with stage IV lung cancer. However, the nuances of how these operations are conducted remain in equipoise, without ample evidence to support the extent of resection or nodal dissection.

CONCLUSIONS

Clear data exist to support the use of surgical resection of the primary lung tumor as LCT in stage IV lung cancer. Evidence-based recommendations have been provided to guide multidisciplinary teams on the implementation of treatment plans as well as to guide researchers on areas of ongoing need for further investigation.

[Recommendations for the management of oligometatic NSCLC]

The concept of oligometastatic disease in lung cancer has been the subject of much publication and speculation. Indeed, beyond its definition, which is still a matter of debate, it is a rather broad concept considering synchronous oligometastatic disease but also oligoprogression and oligopersistence concepts. These questions are increasingly common considering the improvement of systemic treatments in recent years. Although no prospective randomized trial has been conducted to date, it would seem appropriate to offer patients local ablative treatment of oligoprogression, especially if symptomatic or in cases of oncogenic addiction. On the other hand, the most recent data do not defend the closure treatment approach for patients who benefit from immunotherapy. All in all, it is important to remember that systemic therapy remains the cornerstone of treatment for metastatic lung cancer, and that further robust randomized studies will be needed to determine the place of local therapy.

Efficacy of Selpercatinib in Non-small Cell Lung Cancer With Bilateral Internal Auditory Canal Metastases: A Case Report

Selpercatinib is a selective rearranged during transfection (RET) inhibitor approved for treating RET fusion-positive non-small cell lung cancer (NSCLC), demonstrating high efficacy in central nervous system involvement. This case report describes a 65-year-old woman with stage IV lung adenocarcinoma who, after progression on third-line therapy, developed severe neurological symptoms, including hypoacusis, headache, and dizziness, attributed to cerebral and bilateral internal auditory canal metastasis. This study received a favorable opinion from the ethics committee of the Cova da Beira Local Health Unit and informed consent was obtained from the patient in question. Next-generation sequencing identified a RET fusion mutation, leading to the initiation of selpercatinib as a fourth-line treatment. The patient exhibited significant clinical improvement within one week of therapy, including complete hearing recovery. Adverse effects were limited to elevated hepatic transaminases and QT interval prolongation, both of which were effectively managed through dose adjustments. The response to selpercatinib was sustained for over 31 months, at which point new brain metastasis developed, which was possible to address with whole-brain radiotherapy while maintaining targeted therapy with selpercatinib. This case highlights a rare presentation of bilateral auditory canal metastasis in NSCLC with RET fusion, following the failure of platinum-based chemotherapy and immunotherapy. The prolonged progression-free survival and favorable tolerability of selpercatinib, after dose modifications, underscore its potential as an effective treatment option for patients with central nervous system metastasis.

New Treatment Strategies in Advanced Epidermal Growth Factor Receptor-Driven Non-Small Cell Lung Cancer: Beyond Single Agent Osimertinib

Osimertinib has been the standard treatment for advanced Epidermal Growth Factor Receptor (EGFR)-driven non-small cell lung cancer (NSCLC) for many years. However, even with remarkable response rate, progression-free survival (PFS) and survival benefit as compared to the old generation EGFR tyrosine kinase inhibitors (TKIs) gefitinib and erlotinib, treatment outcomes for these subsets of patients remain a challenge. Recently, in order to go beyond osimertinib, new treatment strategies have been developed. In particular, in the FLAURA 2 phase III randomized trial, the combination of platin-based chemotherapy and osimertinib showed impressive PFS benefits as compared to single-agent osimertinib. Furthermore, in the MARIPOSA phase III randomized study, the combination of the anti-EGFR and anti-MET monoclonal antibody amivantamab combined with the new anti-EGFR TKI lazertinib demonstrated remarkable PFS benefit as compared to single agent osimertinib. This paper will discuss these new treatment options and potential selection criteria for personalized treatment of patients.

Drug Resistance in Late-Stage Epidermal Growth Factor Receptor (EGFR)-Mutant Non-Small Cell Lung Cancer Patients After First-Line Treatment with Tyrosine Kinase Inhibitors

The development of tyrosine kinase inhibitors (TKIs) for late-stage epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) represented a drastic change in the treatment of late-stage lung cancer. Drug resistance develops after a certain period of first-line TKI treatment, which has led to decades of changing treatment guidelines for EGFR-mutant NSCLC. This study discussed the potential mechanisms of drug resistance against first-line TKI treatment and potential successive treatment strategies. Next-generation sequencing (NGS) may play a role in the evaluation of drug resistance in first-line TKI treatment. Emerging combination regimens and ongoing trials were discussed. Potential future strategies for treatment and for the management of drug resistance were proposed in this study.

Population-Adjusted Indirect Treatment Comparisons of Repotrectinib Among Patients with ROS1+ NSCLC

BACKGROUND

Head-to-head evidence comparing repotrectinib against other approved ROS1 tyrosine kinase inhibitors (TKIs) is not currently available. The objective of this study was to indirectly compare progression-free survival (PFS), the objective response rate (ORR), and the duration of response (DoR) for repotrectinib vs. crizotinib and vs. entrectinib in patients with TKI-naïve ROS1+ locally advanced or metastatic non-small-cell lung cancer (aNSCLC).

METHODS

Using evidence from a systematic literature review, unanchored matching-adjusted indirect comparisons (MAICs) were used to estimate population-adjusted hazard ratios (HRs) for PFS and DoR and odds ratios (ORs) for ORR for repotrectinib vs. crizotinib and vs. entrectinib among patients with TKI-naïve aNSCLC. The MAICs were adjusted for imbalances in baseline patient characteristics that were pre-specified as being prognostic or predictive of treatment effects. Weighted Cox (for PFS and DoR) and logistic (for ORR) regression models were fit. Supplementary analyses (SAs) explored the impact of missing data and modeling assumptions on effect estimates.

RESULTS

The evidence base was formed by TRIDENT-1 EXP-1 (repotrectinib; N = 71), a pooled set of five trials involving crizotinib (N = 273), and the pooled ALKA-372-001/STARTRK-1 and -2 trials (entrectinib; N = 168). After population adjustment, repotrectinib was associated with statistically significant improvements in PFS relative to crizotinib (HR = 0.44; 95% confidence interval [CI]: 0.29, 0.67) and entrectinib (HR = 0.57; 95% CI: 0.36, 0.91). Differences in ORR and DoR were not statistically significant but numerically favored repotrectinib. SAs were consistent with the main analyses across all comparisons.

CONCLUSIONS

The analysis demonstrated the strong benefits of repotrectinib in PFS, which was robust across different SAs and supported by numerically favorable results for DoR (where available) and ORR. These results, alongside the published TRIDENT-1 clinical data, further support repotrectinib as a potential new standard of care for TKI-naïve patients with ROS1+ aNSCLC.

Body Weight Gain Associated With Alectinib in Patients With ALK+ Non-Small Cell Lung Cancer: Pooled Analysis of Individual Patient Data From Four Prospective Clinical Trials

PURPOSE

Weight gain is a known adverse event (AE) of alectinib. This study evaluates the progression of actual weight gain over time and explores its association with baseline characteristics.

METHODS

A pooled analysis of individual patient data from four clinical trials (ALEX, J-ALEX, ALUR, and ML29453) was conducted. Actual weight gain was calculated as the percent change from baseline. A linear mixed model estimated weight change over time and associations between clinical characteristics and weight change.

RESULTS

Follow-up weights were available for three trials (J-ALEX, ALUR, and ML29453) and missing for ALEX. In total, 2,622 weights were recorded in the first year (N = 302). At baseline, 13.6% of the Japanese population were underweight and 5.0% in the Western population. Actual weight gain of any grade was substantially higher than reported AE rates (49% v 5%), with 18% experiencing ≥10% weight gain (from median 55.6 kg to 64.1 kg). Time on alectinib was positively associated with weight change (β = .37; 95% CI, 0.24 to 0.51; P < .001), corresponding to an average increase of 4.4% over 1 year. Baseline BMI was not associated with weight change in J-ALEX (β = -.090 [95% CI, -0.19 to 0.012]; P = .092) and ALUR/ML29453 (β = -.016 [95% CI, -0.077 to 0.044]; P = .59). Baseline albumin was positively associated with weight change in ALUR/ML29453 (β = .084 [95% CI, 0.027 to 0.14]; P = .0045), although not considered a clinically meaningful predictor.

CONCLUSION

Weight gain is under-reported as AE in trials. Actual weights showed ≥10% weight gain in 18% of patients. Clinicians should be aware of this AE, emphasizing the importance of timely identification and monitoring weight. Identifying predictors for weight gain remains challenging.

Prognostic and predictive effects of TP53 co-mutation in patients with non-small cell lung cancer with rare treatable driver mutations

BACKGROUND

TP53 mutations (TP53-MUT) are common in NSCLC and have been reported as predictive of response and prognostic of poor outcome in EGFR-mutant NSCLC. The impact of TP53-MUT in NSCLCs with rarer driver mutations and approved targeted treatments is unclear.

METHODS

Records of 436 patients were reviewed and associations between TP53 status, demographics, and outcomes (overall response [ORR], survival [OS] and progression-free survival [PFS], and incidence of brain metastases [BM]), were investigated.

RESULTS

TP53-MUTs were found in 184/436 (42.4 %) with a significant demographic difference noted in stage distribution (p = 0.044). Median (m)OS was significantly shorter in TP53-MUT at 23.3 m (95 %CI 19.6-30.7) v 66.4 m (CI 55.0-not reached [NR]) (stage adjusted harzard ratio [aHR] 2.62, CI 1.98-3.46, p < 0.001). mRFS in early stage trended towards worse outcomes in TP53-MUT (p = 0.142). mPFS on first line treatment was shorter in TP53-MUT 5.0 m (CI 3.4-7.6) v 10.0 m (CI 6.1-13.5) (aHR 1.64, CI 1.23-2.19, p < 0.001). ORR to first instance of targeted treatment was 62 % v 70 % (TP53-MUT v WT) with more progressive disease as best response 24 % v 11 % (p = 0.0177). TP53-MT had a non-significant trend towards more BM at any point (46 % v 34 % p = 0.063) and a higher cumulative incidence of BM in stage I-III patients (Gray's test p < 0.001). When comparing disruptive versus non-disruptive TP53 mutations, there were no significant differences in demographics or survival outcomes.

CONCLUSIONS

Co-occurring TP53 variants with rare driver mutations are predictive of a poor response to targeted treatments and associated with shorter OS and PFS in NSCLC.

Durable Response of Pembrolizumab for EGFR Mutation-positive Lung Adenocarcinoma with Early Progression to Osimertinib in First-line Treatment

Osimertinib, a third-generation epidermal growth factor receptor tyrosine kinase inhibitor, is the standard first-line treatment for EGFR mutation-positive non-small-cell lung cancer (NSCLC) and demonstrates favorable disease control. Conversely, immune checkpoint inhibitors (ICIs) that target programmed cell death-1/programmed cell death ligands demonstrate a restrictive tumor response. We herein report a patient who achieved a durable response to pembrolizumab following early progression within two months of osimertinib administration for EGFR mutation-positive lung adenocarcinoma. Our findings suggest that treatment with ICIs for patients with EGFR mutation-positive NSCLC experiencing early progression to osimertinib as first-line treatment might represent a viable approach.

Prognostic Value of Tumor Dissemination (Dmax) Derived from Basal 18F-FDG Positron Emission Tomography/Computed Tomography in Patients with Advanced Non-Small-Cell Lung Cancer

Objectives: The aim of the present study was to test whether a parameter reflecting tumor dissemination (Dmax), derived from basal 18F-FDG PET/CT, may predict clinical outcome in patients with advanced non-small-cell lung cancer (NSCLC). Methods: A total of 78 patients (55 men, 23 women) with stage III and IV NSCLC who had undergone whole-body 18F-FDG PET/CT scan at diagnosis were included in this study. Imaging parameters of primary lung tumors along with total MTV (MTVTOT) and whole-body TLG (TLGWB) of all malignant lesions were determined. Moreover, the largest distance between two 18F-FDG avid lesions (Dmax) in each patient was measured. Univariate and multivariate analyses of clinical and imaging variables were performed followed by overall survival (OS) curves. Results: A total of 441 lesions were analyzed, including 78 primary tumors, 174 metastatic lymph nodes, and 189 distant metastases. In primary tumors, the average values of SUVmax, SUVmean, MTV, and TLG were 11.80 ± 5.73, 5.37 ± 2.09, 60.61 ± 102.57 mL, and 340.36 ± 558.40 g, respectively. The mean value of Dmax was 29.98 ± 20.98 cm, whereas the average values of MTVTOT and TLGWB were 155.90 ± 176.94 mL and 851.08 ± 1032.17 g, respectively. In the univariate analysis, OS was predicted by MTVTOT (p = 0.0145), TLGWB (p = 0.0518), Dmax (p = 0.0031), and stage (p = 0.0130), whereas in the multivariate analysis, only Dmax was retained in the model (χ2 = 7.3130, p = 0.0068). In particular, a high Dmax value indicates a worse prognosis. Moreover, the combination of Dmax with MTVTOT was able to improve the prognostic stratification of patients with advanced stages of NSCLC. Conclusions: Dmax, by reflecting tumor dissemination throughout the body, can predict overall survival in NSCLC patients.

Ensartinib for EML4-ALK-positive lung adenocarcinoma with comorbid mutations in TP53, EGFR, and ERBB2: a case report

Background

In non-small cell lung cancer (NSCLC), anaplastic lymphoma kinase (ALK) gene rearrangements are commonly detected in lung adenocarcinoma. ALK-positive (ALK+) patients may occasionally exhibit concurrent genetic alterations that potentially impact prognosis. New therapeutic strategies are needed for ALK+ NSCLC patients with multiple simultaneous gene mutations.

Case presentation

A 58-year-old man was diagnosed with lung adenocarcinoma (stage IVB, T4N3M1c) with an echinoderm microtubule-associated protein-like 4-ALK+ (EML4-ALK+) rearrangement, harboring tumor protein 53 (TP53), epidermal growth factor receptor (EGFR), and receptor tyrosine-protein kinase erbB-2 (ERBB2) mutations. After three cycles of chemotherapy, the patient developed intolerance. Subsequently, ensartinib (225 mg daily) was administered orally on April 14, 2021. After 3 months of ensartinib treatment, the patient achieved a partial response and reached stable disease at six months, which sustained for 30 months till April 8, 2024, with grade 1 rash and no brain metastases. Currently, the patient remains on ensartinib treatment, without disease progression.

Conclusion

This case demonstrates the potential for ensartinib in the treatment of EML4-ALK+ lung adenocarcinoma with multiple gene mutations. Further investigation through clinical trials is needed to evaluate the safety and efficacy of this targeted therapy.

Estimating the Cost-Effectiveness of Tumor Treating Fields (TTFields) Therapy with an Immune Checkpoint Inhibitor or Docetaxel in Metastatic Non-Small Cell Lung Cancer

Purpose

Lung cancer remains a leading cause of cancer-related mortality. Tumor Treating Fields (TTFields) therapy extended survival in patients with metastatic non-small cell lung cancer (NSCLC) on or after platinum-based therapy. This study evaluates the cost-effectiveness of TTFields therapy concomitant with immune checkpoint inhibitors (ICIs) or docetaxel.

Methods

A model-based health economic evaluation estimated lifetime costs, clinical benefits, and humanistic outcomes of TTFields therapy plus ICI or docetaxel versus ICI or docetaxel alone in metastatic NSCLC. The model used clinical data from the LUNAR study, US healthcare cost data, and quality-adjusted life year (QALY) measures.

Results

The addition of TTFields therapy to an ICI or docetaxel resulted in a mean life-year gain of 0.92 and a QALY gain of 0.66, with an incremental cost-effective ratio (ICER) of $89,808 per QALY gained. TTFields therapy plus an ICI had 1.67 additional life years and 1.21 additional QALYs compared to an ICI alone, with an ICER of $58,764 per QALY gained. For TTFields therapy plus docetaxel, the life-year gain was 0.23 and the QALY gain was 0.17, with an ICER of $306,029 per QALY gained. Sensitivity analyses confirmed the robustness of these findings.

Conclusion

The addition of TTFields therapy to an ICI or docetaxel in metastatic NSCLC demonstrates comparable cost-effectiveness to other approved treatments. ICERs fall within the accepted range for US cost-effectiveness thresholds, supporting their use in clinical practice. TTFields therapy extended mean lifetime survival, offering a clinically meaningful and economically justifiable option for patients progressing after platinum-based chemotherapy.

Body Composition Analysis in Metastatic Non-Small-Cell Lung Cancer: Depicting Sarcopenia in Portuguese Tertiary Care

Background/Objectives: Sarcopenia is an emergent prognostic biomarker in clinical oncology. Albeit increasingly defined through skeletal muscle index (SMI) thresholding, the literature cut-offs fail to discern heterogeneous baseline muscularity across populations. This study assesses the prognostic impact of using cohort-specific SMI thresholds in a Portuguese metastatic non-small-cell lung cancer (mNSCLC) cohort. Methods: Retrospective study including mNSCLC patients treated between January 2017 and December 2022. ImageJ v1.54 g was used to assess cross-sectional CT imaging at the third lumbar vertebra (L3) and calculate L3SMI. Sarcopenia was defined both according to Prado et al. and L3SMI thresholds derived from receiver operating characteristic analysis. Overall survival (OS) was the primary endpoint. Secondary endpoints included first-line (1L) progression-free survival (PFS) and sarcopenia subgroup analysis regarding body mass index impact on OS. Results: The initial cohort included 197 patients. Mean age was 65 years (±11.31). Most tumors were adenocarcinomas (n = 165) and presented with metastasis (n = 154). SMI was evaluable in 184 patients: cohort-specific thresholds (<49.96 cm2/m2 for men; <34.02 cm2/m2 for women) yielded 46.74% sarcopenic patients (n = 86) versus 66.30% (n = 122) per the literature definition. Cohort-specific thresholds predicted both OS (12.75 versus 21.13 months, hazard ratio [HR] 1.654, p = 0.002) and PFS (7.92 versus 9.56 months, HR 1.503, p = 0.01). Among sarcopenic patients, overweight (HR 0.417, p = 0.01) and obesity (HR 2.723, p = 0.039) had contrasting impacts on OS. Conclusions: Amid reclassification of nearly one-fifth of the cohort, cohort-specific thresholds improved sarcopenia prognostication in mNSCLC. Homogeneity regarding both cancer treatment setting and ethnicity could be key to defining sarcopenia based on SMI.

Analytical and Clinical Validation of the Plasma-Based Guardant360 CDx Test for Assessing HER2 (ERBB2) Mutation Status in Patients with Non-Small-Cell Lung Cancer for Treatment with Trastuzumab Deruxtecan in DESTINY-Lung01/02

This study demonstrates the analytical and clinical validity of the approved (United States and Japan) plasma-based Guardant360 companion diagnostic (CDx) test for selecting patients with human epidermal growth factor receptor 2 (HER2 [ERBB2])-mutated (HER2m) non-small-cell lung cancer (NSCLC) for trastuzumab deruxtecan (T-DXd) treatment. Concordance between the Guardant360 CDx test and the plasma-based AVENIO ctDNA Expanded Kit Assay (AVENIO), as well as the tissue-based clinical trial assays (CTAs) was investigated. Clinical utility was assessed by comparing T-DXd clinical efficacy results of patients in DESTINY-Lung01/02 who tested positive for HER2 mutations using the Guardant360 CDx test to benchmark efficacy results from DESTINY-Lung01/02. Finally, concordance between the Guardant360 CDx test and the tissue-based Oncomine Dx Target (ODxT) test was explored. High concordance was observed between the Guardant360 CDx test versus AVENIO [positive percent agreement (PPA), 98.8%; negative percent agreement (NPA), 91.5%] and CTAs (DESTINY-Lung01 Cohort 2-PPA, 91.0%; NPA, 100%; DESTINY-Lung02 arm 1-PPA, 86.0%; NPA, 100%). Confirmed objective response rates were similar in patients with HER2m NSCLC identified by the Guardant360 CDx test and by CTAs. There was a high level of agreement between the Guardant360 CDx test and the ODxT test. The Guardant360 CDx test demonstrated analytical and clinical validity for identifying patients with HER2m NSCLC for T-DXd therapy; results support plasma-based testing when tissue-based testing is not feasible.

Artificial intelligence for diagnosis and predictive biomarkers in Non-Small cell lung cancer Patients: New promises but also new hurdles for the pathologist

The rapid development of artificial intelligence (AI) based tools in pathology laboratories has brought forward unlimited opportunities for pathologists. Promising AI applications used for accomplishing diagnostic, prognostic and predictive tasks are being developed at a high pace. This is notably true in thoracic oncology, given the significant and rapid therapeutic progress made recently for lung cancer patients. Advances have been based on drugs targeting molecular alterations, immunotherapies, and, more recently antibody-drug conjugates which are soon to be introduced. For over a decade, many proof-of-concept studies have explored the use of AI algorithms in thoracic oncology to improve lung cancer patient care. However, despite the enthusiasm in this domain, the set-up and use of AI algorithms in daily practice of thoracic pathologists has not been operative until now, due to several constraints. The purpose of this review is to describe the potential but also the current barriers of AI applications in routine thoracic pathology for non-small cell lung cancer patient care and to suggest practical solutions for rapid future implementation.

Digital counting of tissue cells for molecular analysis: the QuANTUM pipeline

The estimation of tumor cellular fraction (TCF) is a crucial step in predictive molecular pathology, representing an entry adequacy criterion also in the next-generation sequencing (NGS) era. However, heterogeneity of quantification practices and inter-pathologist variability hamper the robustness of its evaluation, stressing the need for more reliable results. Here, 121 routine histological samples from non-small cell lung cancer (NSCLC) cases with complete NGS profiling were used to evaluate TCF interobserver variability among three different pathologists (pTCF), developing a computational tool (cTCF) and assessing its reliability vs ground truth (GT) tumor cellularity and potential impact on the final molecular results. Inter-pathologist reproducibility was fair to good, with overall Wk ranging between 0.46 and 0.83 (avg. 0.59). The obtained cTCF was comparable to the GT (p = 0.129, 0.502, and 0.130 for surgical, biopsies, and cell block, respectively) and demonstrated good reliability if elaborated by different pathologists (Wk = 0.9). Overall cTCF was lower as compared to pTCF (30 ± 10 vs 52 ± 19, p < 0.001), with more cases < 20% (17, 14%, p = 0.690), but none containing < 100 cells for the algorithm. Similarities were noted between tumor area estimation and pTCF (36 ± 29, p < 0.001), partly explaining variability in the human assessment of tumor cellularity. Finally, the cTCF allowed a reduction of the copy number variations (CNVs) called (27 vs 29, - 6.9%) with an increase of effective CNVs detection (13 vs 7, + 85.7%), some with potential clinical impact previously undetected with pTCF. An automated computational pipeline (Qupath Analysis of Nuclei from Tumor to Uniform Molecular tests, QuANTUM) has been created and is freely available as a QuPath extension. The computational method used in this study has the potential to improve efficacy and reliability of TCF estimation in NSCLC, with demonstrated impact on the final molecular results.

Durvalumab, Tremelimumab, and Platinum Chemotherapy in EGFR Mutation-Positive NSCLC: An Open-Label Phase 2 Trial (ILLUMINATE)

Introduction

EGFR-mutant NSCLC is associated with low mutation burden and low levels of PD-L1 expression. We conducted a phase 2 trial to determine the efficacy of durvalumab, tremelimumab, and platinum-pemetrexed in EGFR-mutant NSCLC after progression with EGFR tyrosine kinase inhibitors (TKIs).

Methods

Participants were treated with induction durvalumab, tremelimumab, and platinum-pemetrexed, followed by durvalumab-pemetrexed maintenance. Participants were divided into two cohorts: (1) EGFR exon 20 T790M negative (T790M-, progressing on either first-line osimertinib, or on a single line of first/second generation TKI), and (2) T790M positive (T790M+, progressing on greater than or equal to 1 lines of TKI, including osimertinib). The primary endpoint was the confirmed objective response rate (ORR) assessed by the investigators. Progression-free survival and safety were secondary outcomes.

Results

One hundred participants from Australia and Taiwan were enrolled. Median follow-up was 26 months with 88% and 96% experiencing progression events for T790M- and T790M+, respectively. The ORR for T790M- was 31% (95% confidence interval: 20-45), including two complete responses. The ORR for T790M+ was 21% (95% confidence interval: 12-34). Median durations of response were 9.5 months and 6.3 months for T790M- and T790M+, respectively; median progression-free survival rates were 6.5 months and 4.9 months, respectively. For T790M-, ORR was 27% for 50% or higher PD-L1 (n = 22) and 0% for less than 50% PD-L1 (n = 10), respectively. For T790M+, ORR was 17% for 50% or higher PD-L1 (n = 24). The safety profile was consistent with previous reports.

Conclusions

Durvalumab, tremelimumab, and platinum-pemetrexed had modest anti-tumor activity in EGFR-mutant NSCLC after progression on TKI. The T790M- cohort had higher ORR and a longer duration of response. Immune adverse events were not increased with tremelimumab. The clinical registration number of this trial is NCT03994393.

Targeted therapy for older patients with an oncogene driven non-small cell lung cancer: Recommendations from a SIOG expert group

Lung cancer is mostly a disease of aging with approximately half of newly diagnosed patients being 70 years or older. Treatment decisions in this population pose unique challenges because of their heterogeneity with regards to daily functioning, cognition, organ function, comorbidities and polypharmacy, their underrepresentation in clinical trials and the impact of treatment on patient-centered outcomes, particularly in frail patients. The advent of targeted therapies and immunotherapy has revolutionized the management of advanced non-small cell lung cancer (NSCLC). Molecular profiling has allowed for the identification of actionable genomic alterations and targeted therapies have become standard of care for oncogene-driven NSCLC, significantly improving prognosis and quality of life. However, the data on the efficacy and tolerability of these treatments in older patients remain sparse. This review, conducted by the International Society of Geriatric Oncology (SIOG) NSCLC task force, examines the available literature on the use of targeted therapies in patients aged 70 years or older with oncogene-driven NSCLC. The task force's expert recommendations aim to guide treatment decisions for older patients with oncogene driven NSCLC.

Next-Generation Sequencing Analysis on Image-Guided Biopsy Samples in Early-Stage Lung Cancer: Feasibility Study and Comparison With Surgical Samples

Introduction

Limited information exists on next-generation sequencing (NGS) success for lung tumors of 30 mm or less. We aimed to compare NGS success rates across biopsy techniques for these tumors, assess DNA sequencing quality, and verify reliability against surgical resection results.

Methods

We used data from the Initiative for Early Lung Cancer Research on Treatment study, including patients with lung tumors measuring 30 mm or less who had surgery and NGS on biopsies since 2016. We collected data on biopsy type, nodule characteristics, complications, sequencing feasibility, clinical actionable variants, surgery type, and TNM classification. We compared NGS feasibility and quality between biopsy methods and, for those with NGS on surgical samples, compared feasibility, quality, and detection of actionable variants.

Results

Among the 654 participants with lung tumors of 30 mm or less who underwent surgery, 70 had NGS on prior biopsies. The median age was 68.5; 51.4% were male individuals, and 75.7% were smokers. The mean diameter of biopsied nodules was 17.7 mm, with 67.1% fine-needle aspiration, 17.1% computed tomography-guided transthoracic core needle biopsies, and 17.1% endobronchial ultrasound-guided transbronchial needle aspiration. DNA sequencing was feasible in 97.1% of biopsy samples; 2.9% had low tumor cellularity. Coverage depth was achieved in 89.7% of biopsies. RNA sequencing was successful in 66.2% of biopsies, especially in core needle biopsies. Actionable alterations were found in 41.4% of patients. Among the participants, 30% had NGS on surgical samples. RNA sequencing was more feasible on surgical samples (95.2% versus 42.9% for biopsies). NGS on surgical samples matched biopsy results in 90% of patients, with 10% showing additional alterations.

Conclusion

DNA sequencing succeeded in 97.1% of biopsies of nodules 30 mm or less, whereas RNA sequencing feasibility was lower. NGS on biopsy samples is generally reliable but requires careful review.

Clinical utility of comprehensive genomic profiling in non-small cell lung cancer: An analysis of a nation-wide database

BACKGROUND

Molecular testing is recommended to patients with advanced non-small cell lung cancer (NSCLC) because those who receive targeted therapy have better prognosis than patients who don't. However, recent studies have raised concerns that first-line companion diagnostic testing at diagnosis may have lower detection rates than previously reported. Therefore, we sought to determine the utility of comprehensive genomic profiling (CGP) tests in NSCLC by analyzing a nation-wide database.

METHODS

We searched the Center for Cancer Genomics and Advanced Therapeutics database and downloaded clinical and genomic data from 3,240 lung cancer cases registered from June 2019 to August 2023. Patients undergoing tissue tests and plasma tests were analyzed separately. NSCLC with previously known driver mutations and those without were further analyzed separately. All 3,240 lung cancer patients were analyzed for the presence of germline findings.

RESULTS

We found that 25 % of patients who had negative companion diagnostic results tested positive for driver oncogene mutations with indications for approved inhibitors when they underwent tissue CGP tests. Tissue CGP tests had lower detection rates for gene fusions compared with gene mutations (93 % for mutations and 73 % for fusions, p < 0.001), and plasma CGP tests had lower detection rates for both mutations and fusions compared with tissue testing (69 % for mutations and 37 % for fusions, p < 0.001). Finally, presumed germline pathogenic variants were detected in 3.9-5.3 % of NSCLC patients.

CONCLUSION

NSCLC patients who tested negative for companion diagnostic tests benefited from CGP tests, especially with tissue-based panels. CGP tests detect germline findings in NSCLC patients at rates similar to previous reports.

MOMENT registry: Patients with advanced non-small-cell lung cancer harboring MET exon 14 skipping treated with systemic therapy

Aim: MET exon 14 (METex14) skipping occurs in 3-4% of non-small-cell lung cancer (NSCLC) cases. Low frequency of this alteration necessitated open-label, single-arm trials to investigate MET inhibitors. Since broad MET biomarker testing was only recently introduced in many countries, there is a lack of historical real-world data from patients with METex14 skipping NSCLC receiving conventional therapies. Given the rarity of this population and limitations of existing real-world data sources, the MOMENT registry aims to prospectively collect uniform, comprehensive, high-quality data from patients with METex14 skipping advanced NSCLC treated in routine clinical practice, which can support clinical and regulatory decision making. Patients & methods: MOMENT is a multinational, non-interventional disease registry collecting data on patients with METex14 skipping advanced NSCLC receiving any systemic anticancer therapy. Newly diagnosed patients and those already receiving treatment are eligible. Patients with previous participation in a clinical trial can be included if they receive at least one subsequent therapy line in a routine clinical setting. Eligible systemic treatment includes all available anticancer therapies (approved, conditionally approved or provided through Early Access). Data collection includes biomarker testing results, demographics, baseline clinical characteristics, treatment details and effectiveness, safety information and imaging. Registry site inclusion is dependent on confirmation that local METex14 skipping detection methods are sufficient to confirm METex14 skipping status. MOMENT is currently active at more than 60 sites across Europe and North America and approximately 700 patients are expected to be enrolled within the next 4 years. The first patient was enrolled on 4 October 2022. After completion of data collection, MOMENT data can be shared with external parties to conduct non-interventional studies. Discussion/conclusion: The MOMENT registry collects comprehensive, high-quality real-world data from patients with METex14 skipping advanced NSCLC receiving systemic anticancer treatment in a routine clinical setting, to enable future studies informing regulatory decisions and optimal care for this rare population. Clinical Trial Registration: NCT05376891 (ClinicalTrials.gov); EUPAS47602 (EU PAS register no.).

First-line osimertinib compared to earlier generation TKIs in advanced EGFR-mutant NSCLC: A real-world survival analysis

OBJECTIVES

This study aimed to compare the overall survival (OS) of patients with advanced EGFR-mutant NSCLC treated with first-line osimertinib versus earlier-generation EGFR tyrosine kinase inhibitors (TKIs) in a real-world setting. Secondary endpoint included OS in patients with uncommon EGFR mutations. Exploratory aim focused on the impact of TKIs sequencing strategies.

METHODS

We conducted a retrospective cohort study of patients diagnosed with advanced EGFR-mutant NSCLC who started first-line treatment with either osimertinib or another EGFR TKI (afatinib, erlotinib, or gefitinib) at The Christie (Manchester, UK) from January 2014 to May 2023. Data were extracted from electronic health records, and survival outcomes were analysed using Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

We identified 119 patients treated with first-line osimertinib and 217 with other EGFR TKIs. In the whole population, median age was 69 years (IQR 59.8-77) and 67.3 % of the patients had an ECOG 0-1. With a median follow-up of 73.2 months (95 % CI 66.2-115.7) and 30.6 months (95 % CI 26.0-38.4) in the earlier-generation TKIs and the osimertinib groups, respectively, the median OS was comparable (16.6 vs 16.9 months; HR = 1, p = 0.97). Patients with uncommon EGFR mutations (n = 48; 14.3 %) had poorer survival compared to those with common mutations (HR = 1.664, p = 0.002). Amongst patients who received two treatment lines, those who received osimertinib after another TKI had a shorter OS than those who received osimertinib first-line followed by another line of therapy (HR = 2.062, p = 0.022).

CONCLUSION

First-line osimertinib showed comparable OS to earlier-generation EGFR TKIs for advanced EGFR-mutant NSCLC. Patients with uncommon EGFR mutations had a poorer survival. Further research is warranted to optimize treatment for patients with uncommon EGFR mutations and to explore the cost-effectiveness of different sequencing approaches.

Adjuvant and neo-adjuvant therapy for non-small cell lung cancer without EGFR mutations or ALK rearrangements

Surgical resection is the most effective therapeutic option for the cure in early stage resectable non-small-cell lung cancer (NSCLC). However, despite complete resection, up to 70% of patients die within 5 years mainly due to tumor recurrence in extra-thoracic organs. Adjuvant or neoadjuvant platinum-based chemotherapy may improve postoperative survival, but the absolute survival benefit is modest with an around 5% improvement at 5 years. Recent advance in systemic therapy has changed treatment strategy for advanced unresectable NSCLC, and also has provided a paradigm shift in treatment strategy for resectable NSCLC. For NSCLC without oncogenic driver alterations, immunotherapy using immune-checkpoint inhibitors may improve clinical outcomes in preoperative neoadjuvant setting as well as in postoperative adjuvant setting. Here, we overview recent evidence of adjuvant and neoadjuvant therapy and discuss emerging clinical questions in decision-making of treatment for potentially resectable patients with NSCLC harboring no oncogenic alterations.

Orthoallosteric EGFR-TKIs: A New Paradigm in NSCLC Treatment Strategy Targeting the C797S Mutation

The remarkable clinical success of third-generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) has significantly advanced the treatment landscape for non-small-cell lung cancer (NSCLC). However, the emergence of the tertiary point mutation C797S poses a substantial obstacle to their clinical efficacy, leading to a dearth of FDA-approved targeted therapies for patients harboring this mutation. Addressing this pressing clinical challenge necessitates the development of novel therapeutic agents targeting the clinically challenging EGFR mutation. This review delves into the design strategies, antitumor activity, and crucial protein-drug interactions of recently introduced Orthoallosteric fourth-generation EGFR-TKIs. These inhibitors are distinguished by their ability to simultaneously engage both the canonical orthosteric (ATP) binding site and the allosteric site. By shedding light on these key aspects, the review serves as a valuable resource for medicinal chemists, empowering them to propel the advancement of fourth-generation EGFR inhibitors.

Actionable alterations in glioblastoma: Insights from the implementation of genomic profiling as the standard of care from 2016 to 2023

Background

In 2016, genomic profiling was implemented for patients with grade 4 primary brain tumors at Rigshospitalet, Denmark. The aim of this study was to discover actionable alterations and to match these with targeted therapies.

Methods

Between January 2016 and December 2023, 483 brain tumor patients were profiled. We retrieved clinical data and molecular data. Whole exome, whole genome, or panel sequencing, along with SNP array analyses, and RNA-seq were performed on resected primary tumor tissue. Alterations were classified according to the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT) following the European Association of Neuro-Oncology (EANO) guideline on rational molecular testing.

Results

A total of 200 (41.4%) patients' tumors harbored an alteration of interest according to the EANO guideline. Twenty (4.1%) patients had an ESCAT high-tier alteration (tier I or II), while 155 patients (32.1%) had an alteration corresponding to ESCAT IIIA. Thirty-five patients (7.2%) had an actionable alteration, and 15 (3.1%) received targeted therapy. The treated targets were BRAFV600E mutations, FGFR alterations, NTRK fusions, PDGFRA fusions, PTPRZ1-MET fusions, and TMB-high. The overall response rate was 20%, with a median duration of response of 12 months, and 47% achieved stable disease as the best response.

Conclusions

Genomic profiling uncovers alterations of interest in a substantial number of patients, but only a minority are considered by the Danish National Molecular Tumor Board to have actionable alterations, and even fewer receive targeted therapy. Nevertheless, factors, such as promising targets and the increasing availability of trials, may contribute to a future increase in the number of patients benefiting from targeted therapies based on genomic profiling.

Oligometastatic NSCLC: Current Perspectives and Future Challenges

Oligometastatic non-small cell lung cancer (NSCLC) represents a separate entity with a different biology and prognosis compared to stage IV NSCLC. Challenges range from the very definition of oligometastatic disease to the timing and techniques of local treatments, and their benefit in prolonging patient survival. Most of the international consensus and guidelines agree on the need for shared criteria, such as appropriate stadiation and even tissue biopsy if needed, in order to select patients that could really benefit from personalised strategies. Multidisciplinary evaluation is crucial in order to define if every lesion is amenable to radical local treatment, which appears to be the most important criterion across different guidelines. A distinction must be made depending on the time of oligo-disease detection, separating de novo oligometastatic disease from oligorecurrence, oligoprogression and oligoresidual disease. These separate entities imply a different biology and prognosis, and treatment strategies consequently must be tailored. Locoregional approaches are therefore often contemplated in order to ensure the best outcome for the patient. In non-oncogene-addicted disease, the advent of immune checkpoint blockers (ICBs) allows physicians to take into consideration consolidative treatments, but timing, technique and subsequent systemic treatment remain open issues. In oncogene-addicted NSCLC, local treatments are nowadays preferably reserved to cases of oligoprogression, but the advent of new, more potent drugs might challenge that. In this review, we summarised the current knowledge, consensuses and data from retrospective and prospective trials, with the aim of shedding some light on the topic and emphasising the unmet clinical need.

Circulating Tumor DNA and [18F]FDG-PET for Early Response Assessment in Patients with Advanced NSCLC

Background/Objectives: Identifying treatment failure at earlier time points to could spare cancer patients from ineffective treatment and side effects. In this study, circulating tumor DNA (ctDNA) and [18F]FDG-PET/CT were investigated during the first cycle of anticancer therapy in patients with advanced non-small cell lung cancer (NSCLC) to explore their potential for early response evaluation. Methods: Patients with advanced NSCLC receiving first-line therapy with immune checkpoint inhibitors and/or chemotherapy were included. CtDNA and [18F]FDG-PET/CT assessments were conducted before treatment and at weeks 1 and 3 during the first cycle of therapy. ctDNA quantification was performed using a targeted next-generation sequencing (NGS) panel, and the least favorable change in any mutated allele frequency at a given time was used for analysis. [18F]FDG-PET/CT was quantified using sumSULpeak and metabolic tumor volume (MTV4.0). Early changes in ctDNA levels and [18F]FDG-PET parameters were compared with final treatment response, measured by RECIST after 12 weeks, as well as progression-free survival and overall survival. Results: Of the sixteen included patients, eight were non-responders. ctDNA mutations were detected in baseline blood samples in eight patients. Changes in ctDNA level, MTV4.0, and sumSULpeak at week 3 indicated response in 7 out of 8 patients, 13 out of 15 patients, and 9 out of 15 patients, respectively. At week 3, no false increases were seen with ctDNA and MTV4.0. Conclusions: These results suggest that early changes in ctDNA and [18F]FDG-PET/CT at 3 weeks of treatment could be used to early assess treatment response. Increased levels of ctDNA and MTV4.0 at week 3 were only observed in patients with treatment failure.

Immunotherapy in Oncogene-Addicted NSCLC: Evidence and Therapeutic Approaches

Non-small cell lung cancer (NSCLC) remains a leading cause of cancer-related mortality worldwide. The discovery of specific driver mutations has revolutionized the treatment landscape of oncogene-addicted NSCLC through targeted therapies, significantly improving patient outcomes. However, immune checkpoint inhibitors (ICIs) have demonstrated limited effectiveness in this context. Emerging evidence, though, reveals significant heterogeneity among different driver mutation subgroups, suggesting that certain patient subsets may benefit from ICIs, particularly when combined with other therapeutic modalities. In this review, we comprehensively examine the current evidence on the efficacy of immunotherapy in oncogene-addicted NSCLC. By analyzing recent clinical trials and preclinical studies, along with an overview of mechanisms that may reduce immunotherapy efficacy, we explored potential strategies to address these challenges, to provide insights that could optimize immunotherapy approaches and integrate them effectively into the treatment algorithm for oncogene-addicted NSCLC.

Injecting hope: the potential of intratumoral immunotherapy for locally advanced and metastatic cancer

Despite enormous progress, advanced cancers are still one of the most serious medical problems in current society. Although various agents and therapeutic strategies with anticancer activity are known and used, they often fail to achieve satisfactory long-term patient outcomes and survival. Recently, immunotherapy has shown success in patients by harnessing important interactions between the immune system and cancer. However, many of these therapies lead to frequent side effects when administered systemically, prompting treatment modifications or discontinuation or, in severe cases, fatalities. New therapeutic approaches like intratumoral immunotherapy, characterized by reduced side effects, cost, and systemic toxicity, offer promising prospects for future applications in clinical oncology. In the context of locally advanced or metastatic cancer, combining diverse immunotherapeutic and other treatment strategies targeting multiple cancer hallmarks appears crucial. Such combination therapies hold promise for improving patient outcomes and survival and for promoting a sustained systemic response. This review aims to provide a current overview of immunotherapeutic approaches, specifically focusing on the intratumoral administration of drugs in patients with locally advanced and metastatic cancers. It also explores the integration of intratumoral administration with other modalities to maximize therapeutic response. Additionally, the review summarizes recent advances in intratumoral immunotherapy and discusses novel therapeutic approaches, outlining future directions in the field.

Learning from Other Tumors: Pathways for Progress and Overcoming Challenges in Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a group of complex and heterogeneous tumors originating from the epithelial cells of bile ducts that can occur in intrahepatic, perihilar, or distal localizations [...].

Real-World Outcomes of Pralsetinib in RET Fusion-Positive NSCLC

Introduction

Pralsetinib is a RET inhibitor found to have antitumor activity in advanced, metastatic, RET fusion-positive NSCLC.

Objective

To assess real-world efficacy of pralsetinib and treatment sequences in patients with RET fusion-positive NSCLC.

Design

Retrospective study of consecutive patients enrolled in the French expanded-access program for pralsetinib from December 1, 2019, to December 31, 2021.

Participants

A total of 41 patients with advanced, refractory, RET fusion-positive NSCLC were included. Pralsetinib was administered at a daily dose of 400 mg based on safety and pharmacokinetic outcomes from previous phase 1/2 study.

Results

Pralsetinib was administered as second line in 23 patients (56%) and as third line and beyond in 15 patients (37%). After a median follow-up of 26.3 months, pralsetinib was ongoing in 13 patients. Median real-world progression-free survival was 11.8 (95% confidence interval [CI]: 9.3-15.5) months. Objective response rate was 68% (95% CI: 50%-82%), and disease control rate was 89% (95% CI: 75%-97%). Subsequent line of systemic therapy was initiated in 11 patients. Median overall survival from pralsetinib initiation was 23.8 (95% CI: 16.5-not reached) months.

Conclusion

In this extensive real-world cohort of patients with advanced or metastatic NSCLC harboring RET fusions, we highlight the antitumor efficacy of pralsetinib, particularly when administered in later treatment lines. We also observe the aggressive nature of disease progression, frequent utilization of chemotherapy and antiangiogenic agents as initial subsequent therapies, and limited insight into resistance mechanisms due to infrequent rebiopsy and genomic profiling at progression.