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Ozair MZ, Halmos B, D’Aiello A, Yun J, Filippi AR, Rimner A, Lin SH, Simone CB, Ohri N. Chemotherapy-Free Treatment with Radiotherapy and Immunotherapy for Locally Advanced Non-Small Cell Lung Cancer. Cancers (Basel) 2025; 17:1524. [PMID: 40361451 PMCID: PMC12071140 DOI: 10.3390/cancers17091524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2025] [Revised: 04/23/2025] [Accepted: 04/27/2025] [Indexed: 05/15/2025] Open
Abstract
Background: Concurrent chemoradiotherapy (CRT) followed by immunotherapy is a standard treatment for locally advanced non-small cell lung cancer (LA-NSCLC), yet many patients are ineligible due to treatment-related toxicity or poor functional status. Chemotherapy-free approaches using radiotherapy (RT) and immunotherapy may offer a safer and equally effective alternative in select patient populations. Methods: A comprehensive literature review was conducted using PubMed, Google Scholar, and relevant conference proceedings focusing on trials between 2000 and 2024. Studies investigating chemotherapy-free regimens combining RT and immunotherapy in LA-NSCLC were analyzed, with emphasis on clinical outcomes, biomarker use, treatment sequencing, radiation dose/fractionation, and safety. Results: Multiple Phase I/II trials reported promising efficacy with one-year progression-free survival (PFS) ranging from 39% to 76%. Toxicity was generally acceptable, though higher-grade adverse events were more frequent in older, frail populations. Trials integrating PD-L1 expression, tumor mutational burden (TMB), and circulating tumor DNA (ctDNA) showed potential for improved patient stratification. Variation in immunotherapy timing (induction, concurrent, or consolidation) and radiation schedules highlight the need for optimization. Conclusions: Chemotherapy-free regimens represent a promising treatment strategy for patients with LA-NSCLC, especially those that are ineligible for standard CRT. Biomarker-driven patient selection and the rational integration of RT and immunotherapy are critical to improving outcomes. Randomized trials are warranted to establish the efficacy and safety of these emerging approaches.
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Affiliation(s)
- M. Zeeshan Ozair
- Montefiore-Einstein Comprehensive Cancer Center, Bronx, NY 10461, USA; (B.H.); (A.D.); (J.Y.); (N.O.)
| | - Balazs Halmos
- Montefiore-Einstein Comprehensive Cancer Center, Bronx, NY 10461, USA; (B.H.); (A.D.); (J.Y.); (N.O.)
| | - Angelica D’Aiello
- Montefiore-Einstein Comprehensive Cancer Center, Bronx, NY 10461, USA; (B.H.); (A.D.); (J.Y.); (N.O.)
| | - Jaewon Yun
- Montefiore-Einstein Comprehensive Cancer Center, Bronx, NY 10461, USA; (B.H.); (A.D.); (J.Y.); (N.O.)
| | - Andrea R. Filippi
- Department of Oncology and Hematology-Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, University of Milan, 20133 Milano, Italy;
| | - Andreas Rimner
- Department of Radiation Oncology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK), Partner Site DKTK-Freiburg, 79106 Freiburg, Germany;
| | - Steven H. Lin
- Department of Thoracic Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Charles B. Simone
- New York Proton Center, New York, NY 10461, USA;
- Memorial Sloan Kettering Cancer Center, New York, NY 10461, USA
| | - Nitin Ohri
- Montefiore-Einstein Comprehensive Cancer Center, Bronx, NY 10461, USA; (B.H.); (A.D.); (J.Y.); (N.O.)
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2
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Delcuratolo MD, Crespi V, Saba G, Mogavero A, Napoli VM, Garbo E, Cani M, Ungaro A, Reale ML, Merlini A, Capelletto E, Bironzo P, Levis M, Ricardi U, Novello S, Passiglia F. The evolving landscape of stage III unresectable non-small cell lung cancer "between lights and shadows". Cancer Treat Rev 2025; 135:102918. [PMID: 40086102 DOI: 10.1016/j.ctrv.2025.102918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2025] [Revised: 03/03/2025] [Accepted: 03/07/2025] [Indexed: 03/16/2025]
Abstract
Despite PACIFIC set a new milestone in the clinical management of unresectable stage III non-small cell lung cancer (NSCLC), it left some critical questions pending for clinical research: the efficacy of durvalumab in the real-world setting; the activity of less intensive regimens for frail populations; the role of targeted therapies in oncogene-addicted tumors; the selection of subsequent strategies at immunotherapy failure; the efficacy of novel and intensified treatments; the role of molecular biomarkers for patients' selection. This review aims to describe the evolving landscape of unresectable stage III NSCLC and provides an updated overview of the available evidence, analyzing lights and shadows emerging from recent clinical trials and discussing the most relevant challenges of post-PACIFIC era.
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Affiliation(s)
- Marco Donatello Delcuratolo
- Medical Oncology Unit, Foundation IRCCS, Casa Sollievo Della Sofferenza, San Giovanni Rotondo, FG, Italy; Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Veronica Crespi
- Department of Medical Oncology, ASST Sette Laghi, Varese, Italy; Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Giorgio Saba
- Medical Oncology Unit, University Hospital and University of Cagliari, Cagliari 09042, Italy; Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Andrea Mogavero
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Valerio Maria Napoli
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Edoardo Garbo
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Massimiliano Cani
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Antonio Ungaro
- Medical Oncology Unit, San Giuseppe Moscati Hospital, Statte, TA, Italy
| | | | - Alessandra Merlini
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Enrica Capelletto
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Paolo Bironzo
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Mario Levis
- Radiation Oncology Unit, Department of Oncology, University of Turin, AOU Città della Salute e della Scienza, Torino, Italy
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, AOU Città della Salute e della Scienza, Torino, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy
| | - Francesco Passiglia
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy.
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Facheris G, Cossali G, Imbrescia J, La Mattina S, Mataj E, Meli N, Volpi G, Triggiani L, Guerini AE, Levi G, Grisanti S, Buglione di Monale e Bastia M, Borghetti P. Real-World Insights into the Impact of Durvalumab on Stage III Unresectable Non-Small Cell Lung Cancer-A Narrative Review. Cancers (Basel) 2025; 17:874. [PMID: 40075721 PMCID: PMC11899213 DOI: 10.3390/cancers17050874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2025] [Revised: 02/24/2025] [Accepted: 03/02/2025] [Indexed: 03/14/2025] Open
Abstract
INTRODUCTION AND AIM Stage III Non-Small Cell Lung Cancer (NSCLC) has a poor prognosis, with median survival ranging from 9 to 34 months. The PACIFIC trial demonstrated that durvalumab after platinum-based chemoradiotherapy (CRT) improves overall survival (OS) and progression-free survival (PFS). This review evaluates real-world evidence (RWE) on durvalumab's efficacy and safety, focusing on patient characteristics, prognostic factors, treatment protocols, and outcomes beyond progression. MATERIALS AND METHODS A literature search of PubMed, Embase, and Google Scholar identified 49 observational studies published from January 2017 to August 2024 on unresectable stage III NSCLC. Clinical trials, early-stage disease, and alternative treatments were excluded. RESULTS Compared to the PACIFIC trial, real-world patients were older, had poorer ECOG performance (≥2), and more comorbidities like COPD. Despite this, durvalumab provided consistent survival benefits. Positive prognostic factors included non-squamous histology, high PD-L1 expression, and timely durvalumab initiation (≤42 days post-CRT). Most radiotherapy regimens mirrored PACIFIC (54-66 Gy). Concomitant CRT was used in 90% of cases, with sequential CRT for frail patients. Chemotherapy regimens varied. Immune-mediated pneumonitis was a major adverse event, with incidence rates between 15% and 100%. Severe cases led to treatment discontinuation, impacting survival. Treatment beyond progression remains uncertain, with limited benefits from immunotherapy rechallenge. CONCLUSIONS RWE supports durvalumab's efficacy, emphasizing the need for personalized treatment strategies and further research to improve long-term outcomes.
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Affiliation(s)
- Giorgio Facheris
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Gianluca Cossali
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Jessica Imbrescia
- Radiation Oncology Unit, Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy;
| | - Salvatore La Mattina
- Departement of Radiation Oncology, San Matteo Hospital Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 27100 Pavia, Italy;
| | - Eneida Mataj
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Nicole Meli
- Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Medical, ASST-Spedali Civili, University of Brescia, 25123 Brescia, Italy; (N.M.); (S.G.)
| | - Giulia Volpi
- Azienda Ospedaliera Universitaria Integrata Verona, Radiation Oncology, 37126 Verona, Italy;
| | - Luca Triggiani
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Andrea Emanuele Guerini
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Guido Levi
- Pulmonology Department, ASST Spedali Civili di Brescia, 25123 Brescia, Italy;
- Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy
| | - Salvatore Grisanti
- Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Medical, ASST-Spedali Civili, University of Brescia, 25123 Brescia, Italy; (N.M.); (S.G.)
| | - Michela Buglione di Monale e Bastia
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
| | - Paolo Borghetti
- Radiation Oncology Department, ASST Spedali Civili and University of Brescia, 25123 Brescia, Italy; (G.C.); (E.M.); (L.T.); (A.E.G.); (M.B.d.M.e.B.); (P.B.)
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Mouawad A, Boutros M, Chartouni A, Attieh F, Kourie HR. Tumor mutational burden: why is it still a controversial agnostic immunotherapy biomarker? Future Oncol 2025; 21:493-499. [PMID: 39711461 PMCID: PMC11812421 DOI: 10.1080/14796694.2024.2444862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 12/17/2024] [Indexed: 12/24/2024] Open
Abstract
For the past few years, researchers and oncologists have been pushing to find biomarkers that would help predict which treatment option would best work on a patient. Tumor Mutational Burden (TMB) is one of the latest biomarkers that is being studied and considered as a promising agnostic immunotherapy biomarker. However, it still shows controversial results in studies due to the difficulty in finding solid comparable results. This is a consequence of different cutoff definitions among many cancer types, age ranges, and the use of different sequencing assays, in addition to its association with other biomarkers such as PD-L1. Finally, the use of composite biomarkers to assess the genetic signature of a tumor might be the way forward to seriously use TMB as an agnostic biomarker.
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Affiliation(s)
- Antoine Mouawad
- Faculty of Medicine, Université Saint-Joseph de Beyrouth, Beyrouth, Lebanon
| | - Marc Boutros
- Faculty of Medicine, Université Saint-Joseph de Beyrouth, Beyrouth, Lebanon
| | - Antoine Chartouni
- Faculty of Medicine, Université Saint-Joseph de Beyrouth, Beyrouth, Lebanon
| | - Fouad Attieh
- Faculty of Medicine, Université Saint-Joseph de Beyrouth, Beyrouth, Lebanon
| | - Hampig Raphaël Kourie
- Department of Hematology-Oncology, Université Saint-Joseph de Beyrouth, Beyrouth, Lebanon
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Zhang Y, Sun D, Han W, Yang Z, Lu Y, Zhang X, Wang Y, Zhang C, Liu N, Hou H. SMARCA4 mutations and expression in lung adenocarcinoma: prognostic significance and impact on the immunotherapy response. FEBS Open Bio 2024; 14:2086-2103. [PMID: 39322625 PMCID: PMC11609588 DOI: 10.1002/2211-5463.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/20/2024] [Accepted: 09/10/2024] [Indexed: 09/27/2024] Open
Abstract
The switch/sucrose non-fermenting (SWI/SNF) complex family includes important chromatin-remodeling factors that are frequently mutated in lung adenocarcinoma (LUAD). However, the role of one family member, SMARCA4, in LUAD prognosis and immunotherapy sensitivity remains unclear. In the present study, 6745 LUAD samples from the cBioPortal database were used to analyze the relationships between SMARCA4 mutations and patient prognoses and clinical characteristics. Additionally, we examined the correlation between SMARCA4 mutations and prognosis in patients treated with immunotherapy using two immune-related datasets. SMARCA4 mutations and low expression were associated with shorter survival, and mutations were associated with a high tumor mutational burden and high microsatellite instability. SMARCA4 mutations were accompanied by KRAS, KEAP1, TP53 and STK11 mutations. No significant difference was observed in the immunotherapy response between patients with and without SMARCA4 mutations. When KRAS or STK11 mutations were present, immunotherapy effectiveness was poorer; however, when both SMARCA4 and TP53 mutations were present, immunotherapy was more effective. Furthermore, low SMARCA4 expression predicted a higher immunophenoscore, and SMARCA4 expression was correlated with certain immune microenvironment features. Taken together, our results suggest that SMARCA4 mutations and low expression might be associated with poor LUAD prognosis. Additionally, immunotherapy efficacy in patients with SMARCA4 mutations depended on the co-mutant genes. Thus, SMARCA4 could be an important factor to be considered for LUAD diagnosis and treatment.
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Affiliation(s)
- Yuming Zhang
- Precision Medicine Center of OncologyThe Affiliated Hospital of Qingdao University, Qingdao UniversityChina
| | - Dantong Sun
- Department of Medical OncologyNational Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Weizhong Han
- Department of Respiratory MedicineThe Affiliated Hospital of Qingdao UniversityChina
| | - Zhen Yang
- Department of PathologyThe Affiliated Hospital of Qingdao University, Qingdao UniversityChina
| | - Yongzhi Lu
- Department of OncologyQingdao Municipal HospitalChina
| | - Xuchen Zhang
- Precision Medicine Center of OncologyThe Affiliated Hospital of Qingdao University, Qingdao UniversityChina
| | - Yongjie Wang
- Department of Thoracic SurgeryThe Affiliation Hospital of Qingdao UniversityChina
| | - Chuantao Zhang
- Department of OncologyThe Affiliated Hospital of Qingdao UniversityChina
| | - Ning Liu
- Department of OncologyThe Affiliated Hospital of Qingdao UniversityChina
| | - Helei Hou
- Department of OncologyThe Affiliated Hospital of Qingdao UniversityChina
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Wang Y, Wang W, Zhang T, Yang Y, Wang J, Li C, Xu X, Wu Y, Jiang Y, Duan J, Wang L, Bi N. Dynamic bTMB combined with residual ctDNA improves survival prediction in locally advanced NSCLC patients with chemoradiotherapy and consolidation immunotherapy. JOURNAL OF THE NATIONAL CANCER CENTER 2024; 4:177-187. [PMID: 39282582 PMCID: PMC11390629 DOI: 10.1016/j.jncc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/21/2024] [Accepted: 01/30/2024] [Indexed: 09/19/2024] Open
Abstract
Background Liquid biopsy-based biomarkers, including circulating tumor DNA (ctDNA) and blood tumor mutational burden (bTMB), are recognized as promising predictors of prognoses and responses to immune checkpoint inhibitors (ICIs), despite insufficient sensitivity of single biomarker detection. This research aims to determine whether the combinatorial utility of longitudinal ctDNA with bTMB analysis could improve the prognostic and predictive effects. Methods This prospective two-center cohort trial, consisting of discovery and validation datasets, enrolled unresectable locally advanced non-small-cell lung cancer (LA-NSCLC) patients and assigned them to chemoradiotherapy (CRT) or CRT + consolidation ICI cohorts from 2018 to 2022. Blood specimens were collected pretreatment, 4 weeks post-CRT, and at progression to assess bTMB and ctDNA using 486-gene next-generation sequencing. Dynamic ∆bTMB was calculated as post-CRT bTMB minus baseline bTMB levels. Decision curve analyses were performed to calculate Concordance index (C-index). Results One hundred twenty-eight patients were enrolled. In the discovery dataset (n = 73), patients treated with CRT and consolidation ICI had significantly longer overall survival (OS; median not reached [NR] vs 20.2 months; P < 0.001) and progression-free survival (PFS; median 25.2 vs 11.4 months; P = 0.011) than those without ICI. Longitudinal analysis demonstrated a significant decrease in ctDNA abundance post-CRT (P < 0.001) but a relative increase with disease progression. Post-CRT detectable residual ctDNA correlated with significantly shorter OS (median 18.3 months vs NR; P = 0.001) and PFS (median 7.3 vs 25.2 months; P < 0.001). For patients with residual ctDNA, consolidation ICI brought significantly greater OS (median NR vs 14.8 months; P = 0.005) and PFS (median 13.8 vs 6.2 months; P = 0.028) benefit, but no significant difference for patients with ctDNA clearance. Dynamic ∆bTMB was predictive of prognosis. Patients with residual ctDNA and increased ∆bTMB (∆bTMB > 0) had significantly worse OS (median 9.0 vs 23.0 months vs NR; P < 0.001) and PFS (median 3.4 vs 7.3 vs 25.2 months; P < 0.001). The combinatorial model integrating post-CRT ctDNA with ∆bTMB had optimal predictive effects on OS (C-index = 0.723) and PFS (C-index = 0.693), outperforming individual features. In the independent validation set, we confirmed residual ctDNA predicted poorer PFS (median 50.8 vs 14.3 months; P = 0.026) but identified more consolidation ICI benefit (median NR vs 8.3 months; P = 0.039). The combined model exhibited a stable predictive advantage (C-index = 0.742 for PFS). Conclusions The multiparameter assay integrating qualitative residual ctDNA testing with quantitative ∆bTMB dynamics improves patient prognostic risk stratification and efficacy predictions, allowing for personalized consolidation therapy for LA-NSCLC.
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Affiliation(s)
- Yu Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yin Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Canjun Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Xu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuqi Wu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Jiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinghao Duan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Bartolomeo V, Cortiula F, Hendriks LEL, De Ruysscher D, Filippi AR. A Glimpse Into the Future for Unresectable Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 118:1455-1460. [PMID: 38159097 DOI: 10.1016/j.ijrobp.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Valentina Bartolomeo
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Francesco Cortiula
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center, GROW School for Oncology and Reproduction, Maastricht, The Netherlands; Department of Medical Oncology, Udine University Hospital, Udine, Italy
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center, GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Andrea R Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
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8
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Terashima Y, Hakozaki T, Uehara Y, Miyanaga A, Kasahara K, Seike M, Hosomi Y. Prognostic significance of initial tumor shrinkage in patients with stage III non-small cell lung cancer treated with durvalumab following chemoradiotherapy. Int J Clin Oncol 2024; 29:115-123. [PMID: 38032455 DOI: 10.1007/s10147-023-02436-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Baseline tumor size (BTS) is one of the prognostic factors of advanced non-small cell lung cancer (NSCLC) treated with immunotherapy. However, its prognostic value in patients with locally advanced NSCLC receiving durvalumab maintenance therapy remains unclear. METHODS The present study retrospectively reviewed 136 patients with unresectable stage III NSCLC who underwent CRT and durvalumab at two institutions in Japan. The maximum diameter of the target lesion (max BTS) before CRT was measured, the best response to CRT before durvalumab was evaluated, and the impact of the response on durvalumab was explored. Progression-free survival (PFS) and overall survival (OS) were defined as the time from the day of starting durvalumab. RESULTS Of the total cohort, 133 (97.8%) patients had at least one measurable lesion. The best response to CRT resulting in CR, PR, and SD was seen in 0 (0%), 69 (51.9%), and 64 (48.1%) patients, respectively. PFS was significantly longer in the patients with PR than in those with SD after CRT (median not reached vs. 20.0 months; HR: 0.51; P = 0.023). Moreover, the absence of a massive lesion (max BTS < 50 mm) was associated with a superior CRT response (P < 0.001). CONCLUSION The best response to induction CRT was associated with better PFS in patients with stage III NSCLC receiving durvalumab following chemoradiotherapy. Although the absence of a massive lesion was associated with a better response to induction CRT in this cohort, this was not translated into PFS and OS benefit.
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Affiliation(s)
- Yuto Terashima
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-0021, Japan
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Taiki Hakozaki
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-0021, Japan.
- Graduate School of Advanced Science and Engineering, Faculty of Science and Engineering, Waseda University, Tokyo, Japan.
| | - Yuji Uehara
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-0021, Japan
| | - Akihiko Miyanaga
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuo Kasahara
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masahiro Seike
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yukio Hosomi
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-0021, Japan
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Alessi JV, Price A, Richards AL, Ricciuti B, Wang X, Elkrief A, Pecci F, Di Federico A, Gandhi MM, Lebow ES, Santos PMG, Thor M, Rimner A, Schoenfeld AJ, Chaft JE, Johnson BE, Gomez DR, Awad MM, Shaverdian N. Multi-institutional analysis of aneuploidy and outcomes to chemoradiation and durvalumab in stage III non-small cell lung cancer. J Immunother Cancer 2023; 11:e007618. [PMID: 37914383 PMCID: PMC10626762 DOI: 10.1136/jitc-2023-007618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
There is a need to identify predictive biomarkers to guide treatment strategies in stage III non-small cell lung cancer (NSCLCs). In this multi-institutional cohort of 197 patients with stage III NSCLC treated with concurrent chemoradiation (cCRT) and durvalumab consolidation, we identify that low tumor aneuploidy is independently associated with prolonged progression-free survival (HR 0.63; p=0.03) and overall survival (HR 0.50; p=0.03). Tumors with high aneuploidy had a significantly greater incidence of distant metastasis and shorter median distant-metastasis free survival (p=0.04 and p=0.048, respectively), but aneuploidy level did not associate with local-regional outcomes. Multiplexed immunofluorescence analysis in a cohort of NSCLC found increased intratumoral CD8-positive, PD-1-positive cells, double-positive PD-1 CD8 cells, and FOXP3-positive T-cell in low aneuploid tumors. Additionally, in a cohort of 101 patients treated with cCRT alone, tumor aneuploidy did not associate with disease outcomes. These data support the need for upfront treatment intensification strategies in stage III NSCLC patients with high aneuploid tumors and suggest that tumor aneuploidy is a promising predictive biomarker.
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Affiliation(s)
- Joao V Alessi
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Adam Price
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allison L Richards
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Biagio Ricciuti
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Xinan Wang
- Environmental Health, Harvard University, Boston, Massachusetts, USA
| | - Arielle Elkrief
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Federica Pecci
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alessandro Di Federico
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Malini M Gandhi
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam J Schoenfeld
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bruce E Johnson
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark M Awad
- Lowe Center for Thoracic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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10
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Zhang Q, Tao X, Yuan P, Zhang Z, Ying J, Guo L, Li N, Wang S, Li J, Liu Y, Guo W, Zhao S, Wu N. Predictive value of 18 F-FDG PET/CT and serum tumor markers for tumor mutational burden in patients with non-small cell lung cancer. Cancer Med 2023; 12:20864-20877. [PMID: 37965789 PMCID: PMC10709729 DOI: 10.1002/cam4.6665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/16/2023] [Accepted: 09/25/2023] [Indexed: 11/16/2023] Open
Abstract
PURPOSE To investigate the correlations between metabolic parameters (MPs) of 18 F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT), serum tumor markers (STMs), and tumor mutational burden (TMB) in patients with non-small cell lung cancer (NSCLC). MATERIALS AND METHODS In this retrospective study, we enrolled 129 patients with NSCLC (males, 78; females, 51) who underwent baseline TMB and STM tests and 18 F-FDG PET/CT scans before treatment between March 2018 and September 2022. Patients were categorized into TMB-high (TMB ≥10 mutations/Mb; n = 27 [20.9%]) and non-TMB-high (TMB <10 mutations/Mb; n = 102 [79.1%]) groups. Binary logistic regression analyses were performed to determine independent predictors of TMB-high. Univariate and multivariate linear regression analyses were performed to determine independent predictors of TMB level on a log scale. Subgroup analyses for adenocarcinoma (ADC), ADC with EGFR+, ADC with EGFR-, and squamous cell carcinoma (SCC) were performed. RESULTS For ADC, all MPs (SULpeak , SULmax , SULmean , MTV, and TLG) were significantly higher in the TMB-high group than the non-TMB-high group; smoker (odds ratio [OR] = 27.08, p = 0.018), EGFR+ (OR = 0.03, p = 0.033), KRAS+ (OR = 7.98, p = 0.083), high CEA (OR = 33.56, p = 0.029), and high CA125 (OR = 13.68, p = 0.030) were independent predictors of TMB-high; and all MPs showed significant positive linear correlations with TMB on a log scale, with SULpeak as an independent predictor. However, no significant correlation was observed for SCC. CONCLUSION MPs and STMs can predict the TMB level for patients with ADC, and may serve as potential substitutes for TMB with increased value and easy implementation in guiding immunotherapy through noninvasive methods.
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Affiliation(s)
- Qian Zhang
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiuli Tao
- Department of Nuclear Medicine (PET‐CT Center)National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Pei Yuan
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zewei Zhang
- Department of Nuclear Medicine (PET‐CT Center)National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jianming Ying
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Lei Guo
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ning Li
- Department of Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Shuhang Wang
- Department of Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jing Li
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
- Department of Nuclear Medicine (PET‐CT Center)National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ying Liu
- Department of Nuclear Medicine (PET‐CT Center)National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Wei Guo
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Shijun Zhao
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Ning Wu
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
- Department of Nuclear Medicine (PET‐CT Center)National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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11
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Tanimura K, Takeda T, Yoshimura A, Honda R, Goda S, Shiotsu S, Fukui M, Chihara Y, Uryu K, Takei S, Katayama Y, Hibino M, Yamada T, Takayama K. Predictive Value of Modified Glasgow Prognostic Score and Persistent Inflammation among Patients with Non-Small Cell Lung Cancer Treated with Durvalumab Consolidation after Chemoradiotherapy: A Multicenter Retrospective Study. Cancers (Basel) 2023; 15:4358. [PMID: 37686634 PMCID: PMC10486354 DOI: 10.3390/cancers15174358] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Durvalumab consolidation after chemoradiotherapy (CRT) is a standard treatment for locally advanced non-small cell lung cancer (NSCLC). However, studies on immunological and nutritional markers to predict progression-free survival (PFS) and overall survival (OS) are inadequate. Systemic inflammation causes cancer cachexia and negatively affects immunotherapy efficacy, which also reflects survival outcomes. PATIENTS AND METHODS We retrospectively investigated 126 patients from seven institutes in Japan. RESULTS The modified Glasgow Prognostic Score (mGPS) values, before and after CRT, were the essential predictors among the evaluated indices. A systemic inflammation-based prognostic risk classification was created by combining mGPS values before CRT, and C-reactive protein (CRP) levels after CRT, to distinguish tumor-derived inflammation from CRT-induced inflammation. Patients were classified into high-risk (n = 31) and low-risk (n = 95) groups, and the high-risk group had a significantly shorter median PFS of 7.2 months and an OS of 19.6 months compared with the low-risk group. The hazard ratios for PFS and OS were 2.47 (95% confidence interval [CI]: 1.46-4.19, p < 0.001) and 3.62 (95% CI: 1.79-7.33, p < 0.001), respectively. This association was also observed in the subgroup with programmed cell death ligand 1 expression of ≥50%, but not in the <50% subgroup. Furthermore, durvalumab discontinuation was observed more frequently in the high-risk group than in the low-risk group. CONCLUSION Combining pre-CRT mGPS values with post-CRT CRP levels in patients with locally advanced NSCLC helps to predict the PFS and OS of durvalumab consolidation after CRT.
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Affiliation(s)
- Keiko Tanimura
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto 602-8026, Japan; (K.T.); (A.Y.)
| | - Takayuki Takeda
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto 602-8026, Japan; (K.T.); (A.Y.)
| | - Akihiro Yoshimura
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto 602-8026, Japan; (K.T.); (A.Y.)
| | - Ryoichi Honda
- Department of Respiratory Medicine, Asahi General Hospital, Asahi 289-2511, Japan;
| | - Shiho Goda
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto 605-0981, Japan; (S.G.); (S.S.)
| | - Shinsuke Shiotsu
- Department of Respiratory Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto 605-0981, Japan; (S.G.); (S.S.)
| | - Mototaka Fukui
- Department of Respiratory Medicine, Uji-Tokushukai Medical Center, Uji 611-0041, Japan; (M.F.); (Y.C.)
| | - Yusuke Chihara
- Department of Respiratory Medicine, Uji-Tokushukai Medical Center, Uji 611-0041, Japan; (M.F.); (Y.C.)
| | - Kiyoaki Uryu
- Department of Respiratory Medicine, Yao Tokushukai General Hospital, Yao 581-0011, Japan;
| | - Shota Takei
- Department of Pulmonary Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (S.T.); (Y.K.); (T.Y.); (K.T.)
| | - Yuki Katayama
- Department of Pulmonary Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (S.T.); (Y.K.); (T.Y.); (K.T.)
| | - Makoto Hibino
- Department of Respiratory Medicine, Shonan Fujisawa Tokushukai Hospital, Fujisawa 251-0041, Japan;
| | - Tadaaki Yamada
- Department of Pulmonary Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (S.T.); (Y.K.); (T.Y.); (K.T.)
| | - Koichi Takayama
- Department of Pulmonary Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (S.T.); (Y.K.); (T.Y.); (K.T.)
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12
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Oh S, Botros GN, Patel M, Haigentz M, Patel E, Kontopidis I, Langenfeld J, Deek MP, Jabbour SK. Locally Advanced Lung Cancer. Hematol Oncol Clin North Am 2023; 37:533-555. [PMID: 37024391 DOI: 10.1016/j.hoc.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Consolidation immunotherapy after concurrent chemoradiation has improved five-year survival rates in unresectable, locally advanced lung cancer, but disease progression and treatment personalization remain challenges. New treatment approaches with concurrent immunotherapy and consolidative novel agents are being investigated and show promising efficacy data, but at the risk of additive toxicity. Patients with PD-L1 negative tumors, oncogenic driver mutations, intolerable toxicity, or limited performance status continue to require innovative therapies. This review summarizes historical data that galvanized new research efforts, as well as ongoing clinical trials that address the challenges of current therapeutic approaches for unresectable, locally advanced lung cancer.
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Affiliation(s)
- Sarah Oh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - George N Botros
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Milan Patel
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Missak Haigentz
- Division of Thoracic Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Eshan Patel
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Iaonnis Kontopidis
- Department of Surgery, Robert Wood Johnson University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John Langenfeld
- Division of Thoracic Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.
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