Worldwide Prevalence of Epidermal Growth Factor Receptor Mutations in Non-Small Cell Lung Cancer: A Meta-Analysis

An evaluation of patritumab deruxtecan for the treatment of EGFR-mutated non-small cell lung cancer

INTRODUCTION

Epidermal growth factor receptor (EGFR) mutations represent targetable alterations in non-small cell lung cancer (NSCLC). The treatment landscape in the frontline setting for patients with advanced EGFR-mutated NSCLC is evolving with increasing treatment options. EGFR tyrosine kinase inhibitors (TKIs) have significantly improved outcomes, but resistance inevitably develops, necessitating alternative strategies.

AREAS COVERED

Patritumab deruxtecan is a novel antibody-drug conjugate targeted human epidermal growth factor receptor-3 (HER3), delivering a topoisomerase-I inhibitor payload to HER3-expressing cancer cells. Phase I and II studies have demonstrated efficacy in patients with EGFR-mutant NSCLC with disease progression after prior therapies, including third-generation EGFR TKIs and platinum-based chemotherapy. The phase-II trial reported an objective response rate of 39% and a median progression-free survival of 5.5 months. Patritumab deruxtecan is associated with notable toxicities, including grade 3 and higher hematologic adverse events, gastrointestinal toxicity, and interstitial lung disease (ILD). ILD occurred in 5.3% of patients in the Phase-II study. Early detection and management are crucial to minimizing the risk of complications.

EXPERT OPINION

Patients with advanced EGFR-mutant NSCLC who have received TKI therapy and chemotherapy have limited treatment options. Patritumab deruxtecan demonstrates clinical activity in this population with manageable side effects, addressing an unmet need for patients.

Artificial intelligence in predicting EGFR mutations from whole slide images in lung Cancer: A systematic review and Meta-Analysis

BACKGROUND

Epidermal growth factor receptor (EGFR) mutations play a pivotal role in guiding targeted therapy for lung cancer, making their accurate detection essential for personalized treatment. Recently, artificial intelligence (AI) has emerged as a promising tool for identifying EGFR mutation status from digital pathology images. This systematic review and meta-analysis evaluate the diagnostic accuracy of AI models in predicting EGFR mutations from whole slide images (WSIs) in lung cancer patients.

METHODS

A comprehensive search was conducted across four databases (EMBASE, PubMed, Web of Science, and Scopus) for studies published up to June 20th, 2024. Studies employing AI algorithms, including machine learning and deep learning techniques, to predict EGFR mutations from digital pathology images were included. The risk of bias and applicability concerns were assessed using the QUADAS-AI tool. Diagnostic accuracy metrics such as sensitivity, specificity, and the Area Under the Curve (AUC) were extracted. Random-effects models were applied to synthesize the AI model performance. This study is registered with PROSPERO (CRD42024570496).

RESULTS

Out of 1,828 identified studies, 16 met the inclusion criteria, with 4 eligible for meta-analysis. The pooled results demonstrated that AI algorithms achieved an AUC of 0.756 (95% CI: 0.669-0.824), a sensitivity of 66.3% (95% CI: X-Y), and a specificity of 68.1% (95% CI: X-Y). Subgroup analyses revealed that AI models using in-house datasets, surgical resection samples, the ResNet architecture, and tumor-focused regions exhibited improved predictive performance.

CONCLUSION

AI models exhibit potential for non-invasive prediction of EGFR mutations in lung cancer patients using WSIs, although current accuracy and precision warrant further refinement. Future research should aim to enhance AI algorithms, validate findings on larger datasets, and integrate these tools into clinical workflows to optimize lung cancer management.

Results from a phase Ib study of telisotuzumab vedotin in combination with osimertinib in patients with c-Met protein-overexpressing, EGFR-mutated locally advanced/metastatic non-small-cell lung cancer (NSCLC) after progression on prior osimertinib

BACKGROUND

Osimertinib is the standard first-line treatment for advanced epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC). However, treatment resistance is inevitable and increased c-Met protein expression correlates with resistance. Telisotuzumab vedotin (Teliso-V) is an antibody-drug conjugate that targets c-Met protein overexpression. In this article, we report the results of a phase I/Ib trial evaluating Teliso-V plus osimertinib in patients with NSCLC after progression on osimertinib.

PATIENTS AND METHODS

This multicenter, open-label study (NCT02099058) enrolled patients with advanced EGFR-mutated, c-Met protein-overexpressing, non-squamous NSCLC that had progressed on prior osimertinib. Patients received Teliso-V (intravenously, every 2 weeks) plus osimertinib (orally, 80 mg once daily). Teliso-V was evaluated at 1.6 mg/kg in a safety lead-in phase and escalated to 1.9 mg/kg. Dose expansion included both doses. Endpoints included safety and tolerability, pharmacokinetics, objective response rate (ORR), duration of response (DOR), and progression-free survival (PFS).

RESULTS

A total of 38 patients received Teliso-V (1.6 mg/kg, n = 20; 1.9 mg/kg, n = 18) plus osimertinib and were included in this analysis. No dose-limiting toxicities were observed. Most frequent any-grade treatment-emergent adverse events (TEAEs) were peripheral sensory neuropathy (50%), peripheral edema (32%), and nausea (24%). Most common grade 3/4 TEAEs were anemia (11%) and pulmonary embolism (8%). Five TEAEs led to death; none were reported as being related to Teliso-V or osimertinib. The pharmacokinetic profile of Teliso-V plus osimertinib was similar to Teliso-V monotherapy. After a median follow-up of 7.4 months, the ORR was 50.0% per independent central review (ICR) (DOR not reached), and median PFS per ICR was 7.4 months (95% confidence interval 5.4 months-not reached).

CONCLUSIONS

Teliso-V plus osimertinib had promising activity and a manageable safety profile in patients with c-Met protein-overexpressing, EGFR-mutated non-squamous NSCLC after progression on osimertinib. This combination has the potential to address an unmet medical need in this patient population.

PCDHGA10 as a Potential Biomarker of Lung Squamous Cell Carcinoma Based on Bioinformatics and Experimental Verification

Procalcitonin gamma subfamily A, 10 (PCDHGA10) is a member of the procalcitonin gamma gene cluster, which is associated with neuronal synapse development. However, there are lack of studies on the role and potential prognostic value of PCDHGA10 in lung squamous cell carcinoma (LUSC). We analyzed the RNAseq data of PCDHGA10 to compare their expression differences. Then survival analysis, tumor microenvironment (TME) analysis, and mutation analysis were carried out. Additionally, we performed gene ontology (GO) and kyoto gene encyclopedia (KEGG) enrichment analyses to explore potential signal pathways. PCDHGA10 protein expression was evaluated using immunohistochemistry (IHC) on tissue microarrays (HLugS180Su02). By microarray analysis and database analysis, we found that PCDHGA10 was significantly highly expressed in LUSC. Sufferers with elevated PCDHGA10 levels exhibited a worse prognosis, according to the survival analysis. The PCDHGA10 mutation was also linked to LUSC patient prognosis. Besides, PCDHGA10 was closely related to tumor immune cell infiltration and immune checkpoints. In conclusion, PCDHGA10 is expected to become a new molecular marker for LUSC.

Prevalence of EGFR gene mutations in patients with early-stage resectable non-small cell lung cancer in Spain: the ORIGEN study

Background

Geographic variability in epidermal growth factor receptor (EGFR) mutation rates in early-stage non-small cell lung cancer (NSCLC) has been reported. However, the frequency of EGFR mutations in patients with early-stage resected NSCLC in Spain has not been previously investigated. We aimed to determine the prevalence of EGFR mutations in patients with early-stage resected NSCLC in Spain.

Methods

This was an observational, multicenter, cross-sectional study. Sensitizing EGFR mutations were assessed via real-time polymerase chain reaction (PCR)-based molecular analysis with the IdyllaTM EGFR Mutation Test, and next-generation sequencing (NGS) analysis with the OncomineTM Precision Assay.

Results

A total of 172 patients with surgically resected non-squamous NSCLC were analysed. Median age was 67.5 years and 57.6% were male, 96.5% had adenocarcinoma histology and 65% had stage IA/IB. EGFR mutations were found using IdyllaTM EGFR Mutation Test in 25 patients out of 172 patients (14.5%), which consisted of exon 19 deletion in 13 patients (7.6%), exon 21 L858R point mutation in 11 (6.4%), and exon 20 mutation (T790M) in 1 (0.6%) patient. The OncomineTM test was conducted in 128 patients, which detected exon 19 deletions in 10 patients (7.8%), exon 21 mutations in 10 patients (7.8%), and exon 20 insertions in 5 (3.9%) patients. The OncomineTM test was able to detect concurrent mutations in tumor suppressor genes (TP53, PI3KCA, CDKN2A, PTEN) and another actionable alteration beyond EGFR, such as mutations in KRAS G12C (22%), ERBB2 (6%), METex14 (2%), BRAF V600E (2%) and ALK and ROS1 fusions (2%, each).

Conclusions

The prevalence of EGFR mutations in early stage (IA-IIIB), resectable, non-squamous NSCLC observed in our study is consistent with that reported in advanced NSCLC in Spain. Molecular testing is crucial in early-stage NSCLC and can be performed either with single-gene testing or NGS.

New advances in the treatment of EGFR exon20ins mutant advanced NSCLC

The epidermal growth factor receptor (EGFR) exon 20 insertion (ex20ins) mutations, albeit less frequent, are a clinically significant subset within the EGFR mutation landscape of non-small cell lung cancer (NSCLC), accounting for roughly 4%-12% of all EGFR-altered cases. Ranking as the third most prevalent EGFR mutation type, these ex20ins mutations trail the widely recognized EGFR exon 19 deletion (19-Del) and exon 21 L858R substitution. In advanced-stage NSCLC patients with EGFR exon 20 insertion mutations, conventional treatments such as EGFR tyrosine kinase inhibitors (TKIs), chemotherapy, and immunotherapies often yield suboptimal responses, resulting in unfavorable clinical outcomes. This unmet clinical need underscores the urgency to explore innovative targeted therapies. In the realm of precision medicine, targeted agents specifically tailored for EGFR ex20ins mutations have emerged as promising candidates. This review examines the latest research on targeted therapies for EGFR ex20ins mutations, dissecting the mechanisms of action of these agents, evaluating the results of relevant clinical trials, and integrating the evidence in a systematic manner. The aim is to uncover novel therapeutic insights and strategies to optimize the clinical management of patients with EGFR ex20ins mutation-positive NSCLC.

Prevalence of EGFR Mutations in Vietnamese Patients with Resected Early Stage Non-Small Cell Lung Cancer: EARLY-EGFR Study

Introduction

Comprehensive profiling of mutations in the EGFR gene is vital for selecting patients eligible for EGFR targeted therapies.

Methods

We investigated the prevalence of EGFR mutations and treatment patterns in patients with early stage non-small cell lung cancer (NSCLC) in Vietnam as a part of EARLY-EGFR (Clinical Trial Identifier: NCT04742192), a global, real-world study. Consecutive patients with surgically resected stage IA-IIIB, non-squamous NSCLC were diagnosed from August 2021 to June 2022 and were prospectively enrolled from November 2021 to July 2022.

Results

A total 200 patients (age: median [range], 60.0 [30.0-80.0] years) were enrolled from 3 centers; 56.0% were males and 64.0% never smoked. The prevalence of EGFR mutations was 51.0% (102/200) including deletions in exon-19 (49.0%) and exon-21 L858R mutations (33.3%). Females (73.9%, 65/88), patients aged ≥60 years (52.5%, 53/101), nonsmokers (61.2%, 63/103) and those with stage I (55.8%, 67/120) had higher prevalence of EGFR mutations. Multivariate analysis (adjusted odds ratio [aOR]) showed EGFR mutations to be significantly associated (p < 0.05) with female gender (aOR = 5.90), age ≥60 years (aOR = 1.05), and stage III disease (vs stage I) (aOR = 0.30).

Conclusion

These results underscore the need for EGFR testing early in management algorithm of NSCLC in Vietnam to identify patients eligible for targeted therapy in concordance with international guidelines.

EGFR mutation testing across the osimertinib clinical program

OBJECTIVES

EGFR-tyrosine kinase inhibitors, including osimertinib, have revolutionized EGFR-mutated non-small cell lung cancer (NSCLC) treatment; therefore, early identification of EGFR mutations is essential. We report post-hoc analyses of pooled EGFR mutation tissue testing across osimertinib clinical trials, highlighting testing challenges and supporting best practice.

MATERIALS AND METHODS

Pooled central Cobas® EGFR Mutation Test data from nine global osimertinib NSCLC clinical trials were analyzed by specimen type, disease stage, and geographical region for specimen adequacy for testing and valid test results.

RESULTS

Across 4,864 biopsies and 2,402 resections, 91% were adequate for testing, of which 95% of biopsies and 99% of resections had valid test results. Of biopsies, 12% were inadequate for testing (mainly due to insufficient tumor content [42%] and insufficient tissue volume [35%]) and 3% of resections were inadequate (insufficient tumor content [55%] and incorrect specimen preparation [12%]). Inadequacy varied by disease stage, from 3% in resectable stage IA2-IIIA to 10%-15% in first and second/later-line advanced/metastatic settings, and 16% in unresectable stage III. Test success rates among adequate specimens ranged from 93% (unresectable stage III) to 99% (resectable stage IA2-IIIA). Data were similar by geography.

DISCUSSION

Most tissue specimens were adequate for EGFR testing. Inadequacy was commonly due to insufficient tissue volume or tumor content and higher in biopsies versus resections, and unresectable stage III and first-line advanced/metastatic versus other disease stages. Based on these controlled trial data, pre-analytic variables of tissue specimens are a major driver of testing success; hence maintaining optimal conditions from sample collection to biomarker analysis, as well as improving tissue-sampling techniques is critical to increase testing success rates.

TRIAL REGISTRATION NUMBERS

NCT01802632, NCT02094261, NCT02151981, NCT02296125, NCT04035486, NCT02511106, NCT05120349, NCT03521154, NCT04351555.

Application of EGFR-TKIs in brain tumors, a breakthrough in future?

Brain tumors, both primary and secondary, represent a significant clinical challenge due to their high mortality and limited treatment options. Primary brain tumors, such as gliomas and meningiomas, and brain metastases from cancers such as non-small cell lung cancer and breast cancer require innovative therapeutic strategies. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR -TKIs) have emerged as a promising treatment option, particularly for tumors harboring EGFR mutations. This review examines the use of EGFR-TKIs in brain tumors, highlighting both laboratory and clinical research findings. In primary brain tumors and brain metastases, EGFR-TKIs have shown potential in controlling tumor growth and improving patient outcomes. Advanced applications, such as nano-formulated EGFR-TKIs and combination therapies with other pathway inhibitors, are being investigated to improve efficacy and overcome resistance. Challenges such as treatment-related events, resistance mechanisms and blood-brain barrier penetration remain significant hurdles. Addressing tumor heterogeneity through personalized medicine approaches is critical to optimizing EGFR-TKI therapies. This review highlights the need for continued research to refine these therapies and improve survival for patients with brain tumors.

Current insights into the clinico-pathologic characteristics of lung cancer in women

INTRODUCTION

Lung cancer is responsible for premature cancer deaths in women and is the first cause of cancer deaths in women in many countries. The problem of lung cancer in women seems to be underestimated in many aspects, including low participation in clinical trials and screening tests.

AREAS COVERED

Current research progress has contributed to a better understanding of the issue and makes it possible to describe the problem in a new light. In our paper, the problem of lung cancer in women was discussed in a broad aspect, taking into account women's health, the harmful effects of smoking and the current diagnostic and treatment process. The results of treatment also differ in relation to sex. All these aspects of the diversity of women's lung cancer were presented on the basis of newest and most comprehensive literature.

EXPERT OPINION

Lung cancer in women is and will remain an important health problem worldwide, which is justified by epidemiological data, basic research and treatment results.

Real-World Performance of the EasyPGX® Ready Epidermal Growth Factor Receptor Assay for Genomic Testing of Non-Small Cell Lung Cancer Samples

Background/Objectives: Activating epidermal growth factor receptor (EGFR) variants is the most common targetable alteration in non-small cell lung cancer (NSCLC). Clinical decision-making requires fast and reliable detection of EGFR variants in early and advanced NSCLC, but limited available tissue necessitates tissue-sparing approaches and optimized sample management. The objective of this study was to assess the performance of the commercial EasyPGX® ready EGFR assay using real-world clinical NSCLC samples. Methods: A consecutive cohort of 804 non-squamous NSCLC samples was prospectively analyzed with the real-time quantitative polymerase chain reaction (RT-qPCR)-based EasyPGX® ready EGFR assay (Diatech Pharmacogenetics, Jesi, Ancona, Italy) and compared to next-generation sequencing (NGS) assays. Results: NGS revealed conclusive results in 99.7% samples, of which 11.1% had at least one EGFR variant. The most common variants were exon 19 deletions and p.L858R. The RT-qPCR-based assay identified EGFR variants with high accuracy (overall concordance rate 94.3%) over a broad range of clinical sample types, variant allele frequencies, tumor cell contents and deoxyribonucleic acid (DNA) input amounts. Conclusions: This study demonstrates that the EasyPGX® ready EGFR assay is a valid approach for the rapid detection of common EGFR variants in real-world clinical NSCLC samples with DNA inputs as low as 5 ng (less than the 15 ng recommended by the manufacturer), improving sample management in small specimens with limited quantity of nucleic acids.

Nutritional Approach on Management of Diarrhea Induced by EGFR-TKI's in Advanced Non-Small Cell Lung Cancer Patients

Lung cancer remains the leading cause of cancer-related mortality worldwide. Adenocarcinoma is the most prevalent subtype of Non-Small Cell Lung Cancer (NSCLC), and platinum-based chemotherapy is the standard first-line treatment. However, patients harboring EGFR mutations benefit significantly from tyrosine kinase inhibitor (TKI) therapy, which enhances treatment response, prolongs progression-free survival (PFS), and improves overall survival (OS). Despite these advantages, TKI-associated gastrointestinal toxicity, particularly mucositis and diarrhea, poses a major challenge that often affects treatment adherence and patient quality of life. Effective diarrhea management is crucial for maintaining therapeutic continuity, yet current clinical guidelines primarily focus on pharmacological approaches. This review highlights the critical role of nutritional strategies in preventing and mitigating TKI-induced diarrhea. Due to the irritative effects of TKIs on digestion, dietary modifications are crucial. Patients should avoid greasy, spicy, acidic, and high-fiber foods, along with alcohol, soft drinks, and coffee. Steamed, baked, or boiled foods are recommended. Glutamine and probiotics may aid mucosal recovery and microbiota balance. Ongoing nutritional oversight and individualized dietary guidance are essential for patients with NSCLC undergoing TKI therapy. Future research should establish evidence-based dietary guidelines to optimize treatment tolerance, enhance patient well-being, and improve clinical outcomes.

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.

L858R/L718Q and L858R/L792H Mutations of EGFR Inducing Resistance Against Osimertinib by Forming Additional Hydrogen Bonds

Acquired resistance to first-line treatments in various cancers both promotes cancer recurrence as well as limits effective treatment. This is true for epidermal growth factor receptor (EGFR) mutations, for which secondary EGFR mutations are one of the principal mechanisms conferring resistance to the covalent inhibitor osimertinib. Thus, it is very important to develop a deeper understanding of the secondary mutational resistance mechanisms associated with EGFR mutations arising in tumors treated with osimertinib to expedite the development of innovative therapeutic drugs to overcome acquired resistance. This work uses all-atom molecular dynamics (MD) simulations to investigate the conformational variation of two reported EGFR mutants (L858R/L718Q and L858R/L792H) that resist osimertinib. The wild-type EGFR kinase domain and the L858R mutant are used as the reference. Our MD simulation results revealed that both the L718Q and L792H secondary mutations induce additional hydrogen bonds between the residues in the active pocket and the residues with the water molecules. These additional hydrogen bonds reduce the exposure area of C797, the covalent binding target of osimertinib. The additional hydrogen bonds also influence the binding affinity of the EGFR kinase domain by altering the secondary structure and flexibility of the amino acid residues in the domain. Our work highlights how the two reported mutations may alter both residue-residue and residue-solvent hydrogen bonds, affecting protein binding properties, which could be helpful for future drug discovery.

Differentiating Separate Primary Lung Adenocarcinomas From Intrapulmonary Metastases With Emphasis on Pathological and Molecular Considerations: Recommendations From the International Association for the Study of Lung Cancer Pathology Committee

INTRODUCTION

With the implementation of low-dose computed tomography screening, multiple pulmonary tumor nodules are diagnosed with increasing frequency and the selection of surgical treatments versus systemic therapies has become challenging on a daily basis in clinical practice. In the presence of multiple carcinomas, especially adenocarcinomas, pathologically determined to be of pulmonary origin, the distinction between separate primary lung carcinomas (SPLCs) and intrapulmonary metastases (IPMs) is important for staging, management, and prognostication.

METHODS

We systemically reviewed various means that aid in the differentiation between SPLCs and IPMs explored by histopathologic evaluation and molecular profiling, the latter includes DNA microsatellite analysis, array comparative genomic hybridization, TP53 and oncogenic driver mutation testing and, more recently, with promising effectiveness, next-generation sequencing comprising small- or large-scale multi-gene panels.

RESULTS

Comprehensive histologic evaluation may suffice to differentiate between SPLCs and IPMs. Nevertheless, molecular profiling using larger-scale next-generation sequencing typically provides superior discriminatory power, allowing for more accurate classification. On the basis of the literature review and expert opinions, we proposed a combined four-step histologic and molecular classification algorithm for addressing multiple pulmonary tumor nodules of adenocarcinoma histology that encourages a multidisciplinary approach. It is also noteworthy that new technologies combining machine learning and digital pathology may develop into valuable diagnostic tools for distinguishing SPLCs from IPMs in the future.

CONCLUSIONS

Although histopathologic evaluation is often adequate to differentiate SPLCs from IPMs, molecular profiling should be performed when possible, especially in cases with tumors exhibiting similar morphology. This manuscript summarized the previous efforts in resolving the current challenges and highlighted the recent progress in the differentiation methods and algorithms used in categorizing multiple lung adenocarcinomas into SPLCs or IPMs, which are becoming more and more critical in precision lung cancer management.

Novel LZTR1 germline mutation as a mechanism of resistance to osimertinib in EGFR-mutated lung adenocarcinoma: a case report

Background

Tyrosine kinase inhibitors (TKIs) are now the standard of care first-line therapy for epidermal growth factor receptor (EGFR)-mutated advanced non-small cell lung cancer (NSCLC) patients. Despite positive outcomes in most patients, with extended progression-free survival (PFS), a small population of patients respond poorly to these drugs. Complex genetic and non-genetic resistance mechanisms may be the drivers of disease in cancer, but further research is required to identify these mechanisms in the clinic. Germline molecular testing alongside broad-panel somatic next-generation sequencing (NGS) has allowed for detection of resistance mutations in EGFR-mutated NSCLC patients that may be linked with poor response on TKIs.

Case Description

Here, we present a case of an NSCLC patient harboring an EGFR somatic mutation and a concomitant leucine-zipper-like transcriptional regulator-1 (LZTR1) germline mutation. The patient experienced rapid disease progression on first-line EGFR TKI, osimertinib-chemotherapy, combination therapy with a PFS of only 4 months as compared to the median PFS of 27.9 months in the FLAURA2 study.

Conclusions

This case report indicates that identification of germline resistance mutations such as LZTR1 may be associated with poor response to EGFR TKIs. Furthermore, further characterization of these resistance mutations beyond somatic mutations can aid in development of future therapeutic options, which currently do not exist. It is recommended that germline testing be performed as part of the initial patient workup, if available.

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.

Baseline retinoblastoma transcriptional corepressor 1 (Rb1) functional inactivation is a pre-requisite but not sufficient for small-cell histological transformation in epidermal growth factor receptor (EGFR) mutant lung adenocarcinomas post-tyrosine kinase inhibitor therapy

Small-cell transformation is an uncommon mechanism of tyrosine receptor kinase inhibitor (TKI) resistance in epidermal growth factor receptor (EGFR)-mutant lung adenocarcinomas. This study aims to assess the dynamic changes in the molecular landscape and Rb1 functional status in EGFR-mutant lung adenocarcinomas transforming to small-cell carcinomas post-treatment with EGFR-TKIs. This is an ambispective study (2019-2023) wherein the baseline and post-TKI biopsies of EGFR-mutant lung adenocarcinomas with small-cell transformation were subject to Rb1 immunohistochemistry and 72-gene targeted panel next-generation sequencing. Rb1-deficiency was defined as Rb1 protein loss or Rb1retained/p16high/Cyclin-D1low protein expression profile with RB1 mutations. A cohort of EGFR-mutant lung adenocarcinomas without small-cell transformation was included for Rb1 status comparison. Small-cell transformation was diagnosed in 9 patients (10%, 9/84) on their post-TKI biopsy. All their tested baseline adenocarcinoma (n = 7) and post-TKI small-cell carcinoma (n = 9) samples were Rb1-deficient, with additional TP53 (11/11) and PTEN mutations (2/11). Eighteen paired samples from 9 patients without small-cell transformation revealed Rb1-deficiency in one patient (1/9) only. Baseline functional inactivation of Rb1 is nearly universal in EGFR-mutant adenocarcinomas transforming to small-cell carcinomas post-EGFR TKI suggesting that Rb1 loss is prerequisite for small-cell transformation. However, it is likely not sufficient as not all adenocarcinomas with baseline Rb1 loss transform into small-cell carcinomas. Except for TP53 and PTEN, recurrent mutations in other common oncogenes tested were not detected at baseline or at progression. Within the limitation of a small sample size, specific molecular events that drive small-cell transformation remain unclear.

Amivantamab plus lazertinib vs. osimertinib in first-line EGFR-mutant advanced non-small cell lung cancer

INTRODUCTION

The first-line treatment landscape for patients with NSCLC harboring sensitizing EGFR mutations is rapidly evolving. Initially, osimertinib was the one and only option over earlier generation EGFR inhibitors based on the positive PFS and OS results from the FLAURA study.

AREAS COVERED

This paper reviews and compares the pivotal studies that led to the approval of combination treatment with a focus on the efficacy and safety of amivantamab plus lazertinib in the front-line setting. The literature reviewed in this paper primarily includes key studies published in well-established journals and oncological conferences, such as ASCO, ESMO, and NEJM, between 2018 and 2024.

EXPERT OPINION

Recent advancements, including the results of FLAURA-2 and MARIPOSA, have introduced combination therapies that demonstrate enhanced efficacy.

Osimertinib in the Treatment of Epidermal Growth Factor Receptor-Mutant Early and Locally Advanced Stages of Non-Small-Cell Lung Cancer: Current Evidence and Future Perspectives

The treatment of epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer (NSCLC) patients was dramatically revolutionized by the introduction of EGFR tyrosine kinase inhibitors in clinical practice, both in advanced and locally advanced/early stages. The present work focuses on osimertinib use in locally advanced and early NSCLC stages. Phase 3 clinical trials have supported the use of osimertinib as the new standard of care, both in the adjuvant setting and in locally advanced disease. The ADAURA study reported an overall survival (OS) advantage for adjuvant osimertinib in completely resected stage II-IIIA EGFR-mutant tumors, while the LAURA study proved a statistically significant benefit in progression-free survival (PFS) and a delay of central nervous system metastasis development in EGFR-mutant patients treated with osimertinib maintenance after concurrent chemoradiotherapy for locally advanced disease. In the neoadjuvant setting, data on osimertinib's efficacy are conflicting; therefore, the Neo-ADAURA study is evaluating the efficacy and safety of neoadjuvant osimertinib alone or in combination with chemotherapy in patients with stage II-IIIB NSCLC and common EGFR mutations. We discuss several issues that need to be clarified, such as the efficacy of the drug on uncommon mutations, the long-term impact on survival, and the management of resistance mechanisms. Moreover, we report the studies that are trying to identify potential biomarkers of response, such as the circulating tumor DNA (ctDNA), with the aim of selecting patients who will benefit most from osimertinib.

Discovery of STX-721, a Covalent, Potent, and Highly Mutant-Selective EGFR/HER2 Exon20 Insertion Inhibitor for the Treatment of Non-Small Cell Lung Cancer

After L858R and ex19del epidermal growth factor receptor (EGFR) mutations, ex20ins mutations are the third most common class of driver-mutations in non-small cell lung cancer (NSCLC). Unfortunately, first-, second-, and third-generation EGFR tyrosine kinase inhibitors (TKIs) are generally ineffective for ex20ins patients due to insufficient mutant activity and selectivity over wild-type EGFR, leading to dose-limiting toxicities. While significant advances in recent years have been made toward identifying potent EGFR ex20ins mutant inhibitors, mutant vs wild-type EGFR selectivity remains a significant challenge. STX-721 (53) is a potent, irreversible inhibitor of the majority of EGFR/HER2 ex20ins mutants and demonstrates excellent mutant vs wild-type selectivity both in vitro and in vivo. STX-721 is currently in phase 1/2 clinical trials for EGFR/HER2 ex20ins-driven NSCLC.

Possibilities of Overcoming Resistance to Osimertinib in NSCLC Patients with Mutations in the EGFR Gene

The advancement of genetic research has changed the treatment management of non-small cell lung cancer (NSCLC) and opened the era of personalized medicine. Currently, three generations of EGFR tyrosine kinase inhibitors (TKIs) are used in the treatment of NSCLC patients with activating mutations in the EGFR gene, and ongoing clinical trials examine the safety and effectiveness of new third and fourth generations. Osimertinib, a third generation of TKIs that binds irreversibly to abnormal tyrosine kinase, may be applied in various indications in patients with NSCLC: (i) in the second and subsequent lines of therapy in patients with resistance to first-generation or second-generation EGFR TKIs, (ii) in the first line of treatment in monotherapy in NSCLC patients with frequent or rare EGFR mutations, (iii) in combination with chemotherapy in patients with locally advanced or metastatic NSCLC with frequent EGFR mutations, (iv) in consolidation therapy in patients with locally advanced NSCLC who had previously received chemoradiotherapy, (v) in adjuvant treatment of NSCLC patients with stage IB-IIIA undergoing radical surgical resection. Despite the high efficacy of osimertinib in NSCLC patients harboring EGFR mutations, resistance driven in EGFR-dependent or EGFR-independent mechanisms may occur. Since resistance to osimertinib is poorly understood, the following review presents the overview of resistance mechanisms to osimertinib, methodological approaches for the resistance diagnosis, and the up-to-date treatment possibilities for overcoming the resistance process.

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.

Patient-derived xenograft model in cancer: establishment and applications

The patient-derived xenograft (PDX) model is a crucial in vivo model extensively employed in cancer research that has been shown to maintain the genomic characteristics and pathological structure of patients across various subtypes, metastatic, and diverse treatment histories. Various treatment strategies utilized in PDX models can offer valuable insights into the mechanisms of tumor progression, drug resistance, and the development of novel therapies. This review provides a comprehensive overview of the establishment and applications of PDX models. We present an overview of the history and current status of PDX models, elucidate the diverse construction methodologies employed for different tumors, and conduct a comparative analysis to highlight the distinct advantages and limitations of this model in relation to other in vivo models. The applications are elucidated in the domain of comprehending the mechanisms underlying tumor development and cancer therapy, which highlights broad applications in the fields of chemotherapy, targeted therapy, delivery systems, combination therapy, antibody-drug conjugates and radiotherapy. Furthermore, the combination of the PDX model with multiomics and single-cell analyses for cancer research has also been emphasized. The application of the PDX model in clinical treatment and personalized medicine is additionally emphasized.

EFFICACY OF EPIDERMAL GROWTH FACTOR RECEPTOR TYROSINE KINASE INHIBITOR IN TREATING CHOROIDAL METASTASIS FROM NON-SMALL-CELL LUNG CANCER: A 10-Year Review

BACKGROUND/PURPOSE

To describe the clinical characteristics of choroidal metastasis in patients with non-small-cell lung carcinoma and report treatment outcomes following targeted therapy versus conventional radiotherapy and/or chemotherapy.

METHODS

A retrospective review was conducted in 2 hospitals in Hong Kong between 2013 and 2023. Outcomes included tumor response and visual function following treatment.

RESULTS

A total of 25 eyes of 21 Chinese patients with choroidal metastasis secondary to metastatic non-small-cell lung carcinoma were identified. The majority of patients were nonsmokers. At the time of diagnosis, 88% of eyes were visually symptomatic with a mean visual acuity of 20/100. There were 52% of tumors locating within the macula. Tyrosine kinase inhibitor monotherapy, tyrosine kinase inhibitor with radiotherapy, and radiotherapy and/or chemotherapy groups were observed to demonstrate similar tumor response from 1 month and comparable ocular progression-free indices. Untreated patients had deteriorated vision without any tumor response. The tyrosine kinase inhibitor monotherapy group achieved the most rapid and differential vision gain than other groups.

CONCLUSION

Tyrosine kinase inhibitor achieved durable disease control in epidermal growth factor receptor mutation-positive non-small-cell lung carcinoma patients with choroidal metastasis, while improving visual function. Tyrosine kinase inhibitor can be considered as an alternative to conventional orbital radiotherapy or chemotherapy for these patients in view of the rapid visual recovery.

The Risk and Reversibility of Osimertinib-Related Cardiotoxicity in a Real-World Population

INTRODUCTION

Although osimertinib, a third-generation EGFR tyrosine kinase inhibitor, as the first-line therapy for metastatic NSCLC was found to have substantial survival benefits, concerns have arisen regarding its potential cardiotoxicity, particularly in real-world clinical settings. We aimed to investigate the incidence, risk factors, and reversibility of osimertinib-related cardiotoxicity.

METHODS

We analyzed 1126 patients with NSCLC treated with osimertinib from May 2016 to April 2023 in two cancer centers. Osimertinib-related cardiotoxicity was defined as a composite of osimertinib-related cardiac dysfunction (ORCD), newly developed arrhythmia, and cardiac death. Total follow-up duration was 20.6 (10.8-35.2) months.

RESULTS

The osimertinib was administered for a median of 12.4 months. The incidence of osimertinib-related cardiotoxicity was 4.7%. Advanced age (adjusted hazard ratio with 95% confidence interval: 1.07 [1.04-1.09], p < 0.001), a history of heart failure (3.35 [1.67-9.64], p = 0.025), atrial fibrillation (3.42 [1.27-9.22], p = 0.015), and baseline low left ventricle strain (0.87 [0.79-0.96], p = 0.005) were independently associated with development of cardiotoxicity. The recovery rate of ORCD was 82.4%, which did not differ between patients who discontinued medication and those who did not.

CONCLUSIONS

In real-world practice, the incidence of osimertinib-related cardiotoxicity was 4.7%, including 3.4% for ORCD requiring cardiologic intervention, which is higher than previously reported. Given the long-term medication of osimertinib and increased mortality associated with cardiotoxicity, vigilant monitoring is crucial, especially in patients with advanced age, history of heart failure, atrial fibrillation, or decreased baseline left ventricular strain.

Clinical Utility of Liquid Biopsy for the Early Diagnosis of EGFR-Mutant Advanced Lung Cancer Patients in a Real-Life Setting (CLEAR Study)

Background: Lung cancer remains the leading cause of cancer mortality globally with EGFR mutations representing a significant driver in advanced non-small cell lung cancer (aNSCLC). The timely detection of these mutations is critical for initiating targeted therapy, yet tissue biopsy limitations often delay treatment. Methods: This multicenter prospective study evaluated the clinical utility of liquid biopsy (LBx) in real-life settings for the early diagnosis of EGFR mutations in patients with suspected aNSCLC. Circulating tumor DNA (ctDNA) was analyzed using the Cobas EGFR Mutation Test and compared to tissue-based next-generation sequencing (NGS). Results: Among 366 aNSCLC patients tested, LBx demonstrated a significantly shorter median turnaround time (TAT) of 3 days compared to 26 days for tissue NGS (p < 0.001) with 100% specificity and 65% sensitivity for EGFR mutation detection. LBx identified actionable EGFR mutations in cases where tissue biopsy was insufficient or unavailable, enabling 43.7% of patients to commence targeted therapy based on ctDNA results prior to biopsy confirmation. Conclusions: These findings highlight the potential of LBx to reduce diagnostic delays and improve access to personalized therapies in a real-world setting. Integrating LBx into routine diagnostic workflows may address current gaps in molecular testing, ensuring timely and precise treatment for aNSCLC patients.

Screening Criteria Evaluation for Expansion in Pulmonary Neoplasias (SCREEN) II

BACKGROUND

There is a need to expand eligibility criteria for lung cancer screening beyond age and smoking history. In this study, we sought to assess whether light-or-never-smokers and heavy smokers differ in molecular and immunologic markers based on conventional lung cancer screening criteria.

METHODS

We conducted a retrospective review of lung cancer cases from 2005 to 2018 at a tertiary Canadian institution. We used multivariable logistic regression to compare the rate of molecular mutations (KRAS, EGFR, BRAF, PIK3CA, ALK, and PD-L1 [< 1%, 1%-49%, ≥ 50%]) and survival between light-or-never-smokers and heavy smokers.

RESULTS

We included 1156 patients with lung cancer. Overall, 46.4% (National Lung Screening Trial [NLST], n = 536) and 63.3% (Nederlands-Leuvens Long-kanker Screenings Onderzoek [NELSON], n = 732) of the patients were heavy smokers. Using NELSON criteria, screen-ineligible light-or-never-smokers were more frequently from areas at high risk for radon exposure (n = 175 [41.3%]) than screen-eligible heavy smokers (n = 285 [38.9%]). Light-or-never-smokers were more likely to be EGFR-positive in both NLST (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.21-1.37; p = 0.008] and NELSON (OR 0.79, 95% CI 0.28-1.31; p = 0.002) models. Female light-or-never-smokers were more likely than male light-or-never-smokers to be EGFR-positive in NELSON (OR 0.59, 95% CI 0.06-1.12; p = 0.03] but not NLST (OR 0.51, 95% CI 0.02-1.05; p = 0.06) models. Light-or-never-smokers were more often PIK3CA-positive using NLST (OR 1.33, 95% CI 0.54-2.13; p = 0.001) and NELSON (OR 1.19, 95% CI 0.49-1.90; p = 0.001) models. Light-or-never-smokers in the NELSON model were at higher risk of death.

CONCLUSION

Screen-ineligible light-or-never-smokers had a higher rate of EGFR-and PIK3CA-positive lung cancers than screen-eligible heavy smokers when defined using trial-based lung cancer screening eligibility criteria. Molecular profiling, particularly where targeted therapy is available, should be considered in future studies establishing criteria for lung cancer screening.

CONTEXTE

Il faut élargir les critères d'admissibilité au dépistage du cancer du poumon au-delà de l'âge et des antécédents tabagiques. Dans cette étude, nous avons voulu vérifier s'il y a des différences entre les personnes dont le tabagisme est léger, voire nul (groupe 1) et celles qui fument beaucoup (groupe 2) au plan des marqueurs moléculaires et immunologiques selon les critères classiques de dépistage du cancer du poumon. MÉTHODES: Nous avons procédé à une revue rétrospective des cas de cancer du poumon de 2005 à 2018 dans un établissement de soins tertiaires canadien. Nous avons utilisé la régression logistique multivariée pour comparer les taux de mutations moléculaires (KRAS, EGFR, BRAF, PIK3CA, ALK et PD-L1 [< 1 %, 1 %-49 %, ≥ 50 %]) et la survie entre les 2 groupes. RÉSULTATS: Nous avons inclus 1156 cas de cancer du poumon. En tout, 46,4 % (étude NLST [National Lung Screening Trial], n = 536) et 63,3 % (étude NELSON [ Nederlands-Leuvens Longkanker Screenings Onderzoek], n = 732) des malades étaient de gros fumeurs. À partir des critères de l'étude NELSON, le groupe 1, non admissible au dépistage, venait de secteurs à risque élevé d'exposition au radon (n = 175 [41,3 %]) comparativement au groupe 2, admissible au dépistage (n = 285 [38,9 %]). Le groupe 1 était plus susceptible d'être EGFR-positif, tant selon le modèle NLST (rapport des cotes [RC] 0,79, intervalle de confiance [IC] de 95 % 0,21-1,37; p = 0,008), que le modèle NELSON (RC 0,79, IC de 95 % 0,28-1,31; p = 0,002). Dans le groupe 1, les femmes étaient plus susceptibles que les hommes d'être EGFR-positives selon le modèle NELSON (RC 0,59, IC de 95 % 0,06-1,12; p = 0,03), mais non selon le modèle NLST (RC 0,51, IC de 95 % 0,02-1,05; p = 0,06). Le groupe 1 avait plus tendance à être PIK3CA-positif selon les modèles NLST (RC 1,33, IC de 95 % 0,54-2,13; p = 0,001) et NELSON (RC 1,19, IC de 95 % 0,49-1,90; p = 0,001). Selon le modèle NELSON, le groupe 1 était exposé à un risque de mortalité plus élevé.

CONCLUSION

Les personnes dont le tabagisme est léger voire nul qui ne sont pas admissibles au dépistage ont présenté un taux plus élevé de cancer du poumon EGFRet PIK3CA-positifs comparativement aux gros fumeurs, lorsqu'on appliquait les critères d'admissibilité au dépistage du cancer du poumon des 2 essais cités. Il faudrait envisager un profilage moléculaire lors des prochaines études qui porteront sur les critères d'admissibilité au dépistage du cancer du poumon, surtout lorsqu'il existe des modalités thérapeutiques ciblées.

Role of osimertinib plus brain radiotherapy versus osimertinib single therapy in EGFR-mutated non-small-cell lung cancer with brain metastases: A meta-analysis and systematic review

Single-agent osimertinib has improved outcomes in EGFR-mutated lung cancer patients with brain metastases (BMs), but still, 40 % of them will experience an intracranial progression. We performed a systematic review to evaluate the role of brain radiotherapy upfront plus osimertinib. We evaluated articles comparing the use of osimertinib versus osimertinib plus brain radiotherapy. We included 897 patients from nine retrospective studies. Patients treated with combination therapy had an improvement in intracranial progression-free survival (HR 0.76; 95 % CI 0.61-0.94) and overall survival (HR 0.56; 95 % CI 0.36-0.87) with an acceptable safety profile. Osimertinib with upfront brain radiotherapy may be a suitable first-line treatment option for EGFR mutated patients with BMs at diagnosis. The main limitations of this analysis are the retrospective nature and the inability to control for a single variable of interest. Despite that, the combination of osimertinib and upfront brain radiotherapy is a treatment strategy that deserves further prospective trials.

Study Protocol of the Korean EGFR Registry: A Multicenter Prospective and Retrospective Cohort Study in Nonsmall Cell Lung Cancer Patients With EGFR Mutation

INTRODUCTION

The provision of treatment for epidermal growth factor receptor (EGFR)-mutated nonsmall cell lung cancer (NSCLC) patients has increased in Korea. However, multicenter studies on the clinicopathologic dataset and treatment outcomes, using a large-scale dataset, have not been conducted. The current study is a prospective and retrospective multicenter observational cohort study that registers all stages of EGFR-mutated NSCLC patients.

METHODS

The Korean EGFR Registry was designed to enroll 2000 patients with all stages of EGFR-mutated NSCLC from 40 university hospitals across Korea. This study, encompassing both retrospective and prospective cohorts, aims to analyze clinical characteristics, treatment modalities, and outcomes in these patients. Data collection will include patient demographics, smoking history, quality of life assessments, pathological data, and treatment outcomes, with follow-up until December 2026. The primary endpoint is disease-free survival in patients who have undergone radical therapy (surgery and radiotherapy) or progression-free survival in those receiving targeted therapy (first, second, and subsequent lines), chemotherapy (first and subsequent lines), combination therapy, and palliative/maintenance therapy according to stages of EGFR-mutated NSCLC. The study will explore the diagnostic methods for EGFR mutations, clinical outcomes based on treatment modalities, and metastatic patterns in EGFR-mutated NSCLC patients. Moreover, it will investigate various aspects, including the safety and efficacy of a new third-generation EGFR tyrosine kinase inhibitor (TKI), lazertinib, approved for both first- and second-line treatments.

DISCUSSION

This study is expected to provide valuable insights into the epidemiology, risk factors, progression, and treatment outcomes of EGFR-mutated NSCLC in Korea. The Korean EGFR Registry will contribute significantly to the understanding of the complex dynamics of EGFR-mutated NSCLC, aiding in the development of more effective and personalized treatment strategies.

The prevalence and clinical significance of EGFR mutations in non-small cell lung cancer patients in Egypt: a screening study

BACKGROUND

Lung cancer is a form of cancer that is responsible for the largest incidence of deaths attributed to cancer worldwide. Non-small cell lung cancer (NSCLC) is the most prevalent of all the subtypes of the disease. Treatment with tyrosine kinase inhibitors (TKI) may help some people who have been diagnosed with non-small cell lung cancer. The presence of actionable mutations in the epidermal growth factor receptor (EGFR) gene is a key predictor of how a patient will respond to a TKI. Thus, the frequency of identification of mutations in EGFR gene in patients with NSCLC can facilitate personalized treatment.

OBJECTIVE

The objective of this study was to screen for mutations in the EGFR gene and to investigate whether there is a correlation between the screened mutations and various clinical and pathological factors, such as gender, smoking history, and age, in tissue samples from patients with NSCLC.

METHODS

The study comprised 333 NSCLC tissue samples from 230 males and 103 females with an average age of 50 years. Exons 18-21 of the EGFR gene have been examined using real-time PCR. Using SPSS, correlations between clinical and demographic variables were examined, and EGFR mutation and clinical features associations were studied.

RESULTS

The study's findings revealed that the incidence rate of EGFR mutation was 24.32% (81/333), with partial deletion of exon 19 (19-Del) and a point mutation of L858R in exon 21 accounting for 66.67% (P < 0.001) and 28.40% (P < 0.001) of the mutant cases, respectively. Patients who had the T790M mutation represent 4.94% (P = 0.004) of total number of patients. Females harbored EGFR mutations (54.32%) with higher frequency than men (45.68%) (P < 0.001), while nonsmokers had EGFR mutations (70.37%) more frequently than current smokers (29.63%) (P < 0.001).

CONCLUSION

The screening study conducted in Egypt reported that the EGFR mutations prevalence was 24.32% among Egyptians with NSCLC. The study also found a slight gender bias, with females having an incidence rate of these mutations higher than males. Additionally, nonsmokers had higher rates of mutations in EGFR gene compared to smokers. According to the findings, somatic EGFR mutations can be employed as a diagnostic tool for non-small cell lung cancer in Egypt, and they can be implemented in conjunction with clinical criteria to identify which patients are more likely to respond favorably to TKIs.

Determination of osimertinib concentration in rat plasma and lung/brain tissues

OBJECTIVES

The aim of this study was to establish an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for the detection of osimertinib in rat plasma, lung and brain tissues.

METHODS

Forty-eight rats were randomly divided into an experimental group (receiving osimertinib at doses of 5, 8, and 10 mg/kg) and a control group. After continuous intragastric administration for 15 days, samples of blood, lung, and brain tissue were collected. Chromatographic separation was achieved using a BEH C18 column with gradient elution, employing a mobile phase of water (containing 0.1% (v/v) formic acid) and acetonitrile. The concentration of osimertinib in the samples was determined using an AB SCIEX 5500 triple quadrupole mass spectrometer operated in positive electrospray ionization (ESI+) and multiple reaction monitoring (MRM) mode.

RESULTS

A UPLC-MS/MS analytical method for determining osimertinib concentrations was successfully established and validated. A linear relationship was observed for osimertinib concentrations in plasma within the range of 1-300 ng/mL, and in lung and brain tissues within the range of 0.5-50 ng/mL. The selectivity, accuracy, precision, matrix effect, extraction recovery, and stability all meet the requirements of methodological validation criteria.

CONCLUSIONS

A rapid and sensitive UPLC-MS/MS method was developed and validated for quantifying osimertinib concentrations in rat plasma, lung, and brain tissues, providing a valuable tool for pharmacokinetic and tissue distribution studies.

Small cell transformation in EGFR-mutated non-small cell lung cancer: DLL3 expression and efficacy of immune checkpoint inhibitors or tyrosine kinase inhibitors combined with chemotherapy

INTRODUCTION

Small cell transformation (SCT) is a typical mechanism of adaptive resistance to third generation epidermal growth factor receptor inhibitors (EGFRi) which have become the standard of care for EGFR-driven non-small cell lung cancer (EGFR+ NSCLC). Little is known about the optimal management of SCT patients. This study aimed to compare outcomes under platinum/etoposide chemotherapy alone (chemo) or in combination with EGFR inhibitors (EGFRi+chemo) or immune checkpoint inhibitors (ICI+chemo). In addition, DLL3 expression was explored as potential novel therapeutic target.

METHODS

We conducted a retrospective study on patients with EGFR+ NSCLC and SCT treated at 19 centers in Europe and the United States. A total of 47 patients were included of whom 17 received chemo, 20 ICI+chemo, and 10 EGFRi+chemo. We analyzed DLL3 expression by immunohistochemistry.

RESULTS

In the entire cohort, median overall survival (OS) from start of first SCT therapy was 11 months (95 % confidence interval [95 %CI] 9.1-12.9) and median progression-free survival (PFS) was 5 months (95 %CI 4.2-5.8). Median PFS was similar in all three groups (chemo and ICI+chemo 4 months, EGFRi+chemo 6 months), and 12-months PFS was 12 % (95 %CI 2 %-31 %), 13 % (95 %CI 0 %-43 %), and 0 % for ICI+chemo, EGFRi+chemo, and chemo, respectively. Median OS in the ICI+chemo group was 13 months (95 %CI 5.5-20.5) compared to 10 months (95 %CI 7.6-12.4) with chemo and EGFRi+chemo (95 %CI 8.1-11.9), respectively. Before and after SCT, 0 % and 93 % of tumors were DLL3-positive.

CONCLUSIONS

Our results suggest that ICI+chemo and DLL3-targeting agents are worth further exploration in EGFR+ NSCLC undergoing SCT.

PRESENTED ELSEWHERE

Part of this work has been presented at ESMO annual meeting in Madrid, Spain in October 2023 (Poster 1336 P).

[Non-small cell lung cancer in adults under 40 years of age]

INTRODUCTION

Non-small cell lung cancers (NSCLC) are the most common lung cancers, withpeak incidence at 65years of age. These cancers rarely occur before the age of 40.

METHODS

Based on an illustrative clinical case, a systematic review of the literature was conducted to study the epidemiological, clinical, histological, and biological characteristics of NSCLC in adults under 40years of age. Two equations were developed to search for articles on Medline and Scopus.

RESULTS

Sixty-five articles were included in the review; 1.7% of patients were under 40years old, 50.7% were women, 66.7% presented adenocarcinoma, 51.9% were diagnosed at stage IV, 75% were non-smokers, 39.9% were exposed to other toxins, 33% had an EGFR mutation, 6.6% had a KRAS mutation, 25% had an ALK translocation, 73.7% were symptomatic, and over 75% had PS<2.

CONCLUSION

NSCLC in patients under 40years of age presents characteristics different from those in older patients. Various factors are implicated, one example being lower exposure to tobacco, and they can influence the distribution of histological subtypes and the frequency of mutations.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with oncogene-addicted metastatic non-small-cell lung cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with oncogene-addicted metastatic non-small-cell lung cancer (mNSCLC), published in January 2023, was modified according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with oncogene-addicted mNSCLC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with oncogene-addicted mNSCLC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and the Korean Society for Medical Oncology (KSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different regions of Asia. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with oncogene-addicted mNSCLC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, while respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies between the different regions of Asia.

Anti-EGFR aptamer exhibits direct anti-cancer effects in NSCLC cells harboring EGFR L858R mutations

Non-small cell lung cancer (NSCLC) adenocarcinoma (LUAD) is a leading cause of death worldwide. Activating mutations in the tyrosine kinase domain of the oncogene epidermal growth factor receptor (EGFR) are responsible for ~10-50% of all LUAD cases. Although tyrosine kinase inhibitors (TKIs) have been effective in prolonging patient survival and quality of life, acquired resistance and disease progression are inevitable, presenting a clear unmet need for alternative or adjuvant therapeutics. Here we show that an anti-EGFR aptamer (EGFRapt) decreases viability and tumor growth of LUAD cell lines harboring the L858R ± T790M mutation in EGFR. Additionally, we elucidate the mechanism by which EGFRapt exerts these effects by monitoring cellular processes associated with kinase-dependent and kinase-independent mechanisms. Overall, these data establish that EGFRapt has direct anti-cancer activity in mutant EGFR positive LUAD via targetable mechanisms that are independent of existing approaches, and they provide a foundation for further development of nucleic acid-based therapies that target EGFR.

Biochemical analysis of EGFR exon20 insertion variants insASV and insSVD and their inhibitor sensitivity

Somatic mutations in the epidermal growth factor receptor (EGFR) are a major cause of non-small cell lung cancer. Among these structurally diverse alterations, exon 20 insertions represent a unique subset that rarely respond to EGFR tyrosine kinase inhibitors (TKIs). Therefore, there is a significant need to develop inhibitors that are active against this class of activating mutations. Here, we conducted biochemical analysis of the two most frequent exon 20 insertion variants, V769_D770insASV (insASV) and D770_N771insSVD (insSVD) to better understand their drug sensitivity and resistance. From kinetic studies, we found that EGFR insASV and insSVD are similarly active, but have lower Km, ATP values compared to the L858R variant, which contributes to their lack of sensitivity to 1st-3rd generation EGFR TKIs. Biochemical, structural, and cellular studies of a diverse panel of EGFR inhibitors revealed that the more recently developed compounds BAY-568, TAS6417, and TAK-788 inhibit EGFR insASV and insSVD in a mutant-selective manner, with BAY-568 being the most potent and selective versus wild-type (WT) EGFR. Cocrystal structures with WT EGFR reveal the binding modes of each of these inhibitors and of poziotinib, a potent but not mutantselective inhibitor, and together they define interactions shared by the mutant-selective agents. Collectively, our results show that these exon20 insertion variants are not inherently inhibitor resistant, rather they differ in their drug sensitivity from WT EGFR. However, they are similar to each other, indicating that a single inhibitor should be effective for several of the diverse exon 20 insertion variants.

Machine learning in oncological pharmacogenomics: advancing personalized chemotherapy

This review analyzes the application of machine learning (ML) in oncological pharmacogenomics, focusing on customizing chemotherapy treatments. It explores how ML can analyze extensive genomic, proteomic, and other omics datasets to identify genetic patterns associated with drug responses. This, in turn, facilitates personalized therapies that are more effective and have fewer side effects. Recent studies have emphasized ML's revolutionary role of ML in personalized oncology treatment by identifying genetic variability and understanding cancer pharmacodynamics. Integrating ML with electronic health records and clinical data shows promise in refining chemotherapy recommendations by considering the complex influencing factors. Although standard chemotherapy depends on population-based doses and treatment regimens, customized techniques use genetic information to tailor treatments for specific patients, potentially enhancing efficacy and reducing adverse effects.However, challenges, such as model interpretability, data quality, transparency, ethical issues related to data privacy, and health disparities, remain. Machine learning has been used to transform oncological pharmacogenomics by enabling personalized chemotherapy treatments. This review highlights ML's potential of ML to enhance treatment effectiveness and minimize side effects through detailed genetic analysis. It also addresses ongoing challenges including improved model interpretability, data quality, and ethical considerations. The review concludes by emphasizing the importance of rigorous clinical trials and interdisciplinary collaboration in the ethical implementation of ML-driven personalized medicine, paving the way for improved outcomes in cancer patients and marking a new frontier in cancer treatment.

Management of Pulmonary Toxicities Associated with Systemic Therapy in Non Small Cell Lung Cancer

OPINION STATEMENT

Drug-induced pneumonitis is a common adverse event that may occur during lung cancer systemic therapy. The incidence/prevalence of this side effect has increased due to recent extensive use of immunotherapy. Although pneumonitis prevalence is increased with the use of immune checkpoint inhibitors, it is also associated with chemotherapy and targeted therapy. Pneumonitis can occur early after drug exposure or present after several cycles of treatment. Its severity can range from insidious to fulminant, leading to hospitalization. In most cases, the diagnosis is made based on medical history, temporal correlation with use of lung cancer systemic therapy, and computed tomography (CT) findings. In the majority of cases, stopping the offending drug and use of corticosteroids is the sufficient treatment; however, patients with more severe forms of pneumonitis require additional immunosuppressive agents. In this review, we address pneumonitis caused by chemotherapy, antibody-drug conjugates, targeted therapy, or immunotherapy, and provide a detailed management approach.

A Comprehensive Review of Epidermal Growth Factor Receptor Mutation Abundance in Non-Small Cell Lung Cancer Treated with Tyrosine Kinase Inhibitors

BACKGROUND

Lung cancer is a major contributor to cancer-related death worldwide. Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancers. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) are currently viewed as the established first-line therapy for patients with advanced NSCLC with EGFR mutations.

SUMMARY

The potential predictive value of the quantitative abundance of epidermal growth factor receptor (EGFR) mutations in the treatment of NSCLC is widely recognized and regarded as a significant indicator. The definition of mutation abundance in the EGFR gene in most current studies is mainly calculated based on the ratio of mutation to wild-type gene copy number or based on the ratio of allele number; for example, variant allele frequency is the ratio of the number of mutant alleles to the total number of alleles at a particular locus. Results of the included primary studies are as follows. (1) Significant association between EGFR mutation abundance and progression-free survival (PFS): median PFS was significantly longer in the high abundance group (11.0 months, 95% CI: 9.7-12.3 months) than in the low abundance group (5.3 months, 95% CI: 3.6-7.0 months) in the study by Liu et al. High mutation abundance (HR: 0.77, 95% CI: 0.66-0.82, p = 0.037) was an independent prognostic determinant of PFS in the study by Wang et al. Among patients receiving EGFR-TKI as first-line therapy, the median PFS was significantly longer in the high mutation abundance group than in the low mutation abundance group (12.7 months vs. 8.7 months, p = 0.002). EGFR mutation abundance ≥30% was an independent risk factor for PFS (HR: 1.64, 95% CI: 1.17-2.31). (2) Significant association between EGFR mutation abundance and overall survival (OS): the median OS in the high abundance group in the study by Liu et al. was 20.9 months (95% CI: 18.3-23.5 months), while that in the low abundance group was 13.0 months (95% CI: 10.0 months) (95% CI: 10.3-15.7 months); longer OS was independently associated with high mutation abundance (HR: 0.62, 95% CI: 0.50-0.79, p = 0.027).

KEY MESSAGES

The objective of this article was to conduct a comprehensive examination and analysis of the association between the abundance of EGFR mutations in NSCLC and the effectiveness of treatment with TKIs while also considering the development of drug resistance.

Prevalence of EGFR Mutations in Patients With Resected Stages I to III NSCLC: Results From the EARLY-EGFR Study

INTRODUCTION

There is limited literature on the prevalence of EGFR mutations in early stage NSCLC. EARLY-EGFR (NCT04742192), a cross-sectional study, determined the prevalence of EGFR mutations in early stage NSCLC.

METHODS

This noninterventional, real-world study enrolled consecutive patients with resected stages IA to IIIB (American Joint Committee on Cancer eighth edition) NSCLC from 14 countries across Asia, Latin America, and the Middle East and Africa. The primary end point was prevalence of EGFR mutations and secondary end points included prevalence of EGFR mutation subtypes and treatment patterns.

RESULTS

Of 601 patients (median [range] age: 62.0 [30.0-86.0] y) enrolled, 52.7% were females and 64.2% were nonsmokers. Most had stages IA to IB NSCLC (64.1%) and adenocarcinoma (98.7%). Overall prevalence of EGFR mutations was 51.0%; most reported exon 19 deletions (48.5%) followed by exon 21 L858R mutations (34.0%). Women had a higher EGFR mutation rate than men (64.0% versus 36.4%). Compared with no EGFR mutations, patients with EGFR mutations were more likely to be nonsmokers (35.1% versus 60.9%) and have stage I NSCLC than stages II and III NSCLC (54.8% versus 47.3% and 35.6%). Systemic adjuvant therapy was planned in 33.8% of the patients with stages IB to IIIB disease and adjuvant chemoradiotherapy in 6.8%. Age above or equal to 60 years, females, and Asians were found to have a significantly (p < 0.05) higher odds of EGFR mutations, whereas smoking history and stage III disease had lower odds of EGFR mutations.

CONCLUSIONS

The EARLY-EGFR study provides an overview of EGFR mutations and subtype prevalence in patients with early stage NSCLC. The study highlights the limited adherence to treatment guidelines suggesting an unmet need for improved adjuvant therapy.

Analysis of EGFR binding hotspots for design of new EGFR inhibitory biologics

The epidermal growth factor (EGF) receptor (EGFR) is activated by the binding of one of seven EGF-like ligands to its ectodomain. Ligand binding results in EGFR dimerization and stabilization of the active receptor conformation subsequently leading to activation of downstream signaling. Aberrant activation of EGFR contributes to cancer progression through EGFR overexpression/amplification, modulation of its positive and negative regulators, and/or activating mutations within EGFR. EGFR targeted therapeutic antibodies prevent dimerization and interaction with endogenous ligands by binding the ectodomain of EGFR. However, these antibodies have had limited success in the clinic, partially due to EGFR ectodomain resistance mutations, and are only applicable to a subset of patients with EGFR-driven cancers. These limitations suggest that alternative EGFR targeted biologics need to be explored for EGFR-driven cancer therapy. To this end, we analyze the EGFR interfaces of known inhibitory biologics with determined structures in the context of endogenous ligands, using the Rosetta macromolecular modeling software to highlight the most important interactions on a per-residue basis. We use this analysis to identify the structural determinants of EGFR targeted biologics. We suggest that commonly observed binding motifs serve as the basis for rational design of new EGFR targeted biologics, such as peptides, antibodies, and nanobodies.

Event-free survival as a predictor of overall survival and recurrence burden of patients with non-small cell lung cancer receiving neoadjuvant therapy

OBJECTIVES

Event-free survival has replaced overall survival as a primary end point in many recent and ongoing clinical trials. This study aims to examine the correlation between real-world event-free survival and overall survival and to assess the clinical and economic burden associated with disease recurrence among patients with resected stage II to III non-small cell lung cancer who received neoadjuvant therapy in the United States.

METHODS

This retrospective study used the Surveillance, Epidemiology, and End Results Medicare database (2007-2019) to identify patients with newly diagnosed, resected, stage II to IIIB (N2) non-small cell lung cancer who received neoadjuvant therapy. The correlation between real-world event-free survival and overall survival was assessed using the normal scores rank correlation and landmark analysis. Overall survival, all-cause health care resource use and costs, and non-small cell lung cancer-related health care resource use and costs were compared between patients with and without recurrence.

RESULTS

A total of 221 patients met the eligibility criteria (median follow-up time from neoadjuvant treatment initiation: 32.7 months). The mean age was 72.1 years, and 57.0% of patients were male. Real-world, event-free survival and overall survival are positively and significantly correlated (0.68; 95% CI, 0.52-0.79). Patients with recurrence had significantly shorter median overall survival (19.3 vs 116.9 months), 4.59 times increased risk of death (95% CI, 2.56-8.26), and significantly higher all-cause and non-small cell lung cancer-related health care resource use and costs (adjusted mean monthly costs per patient difference: $5758 and $3187, respectively [all P < .001]).

CONCLUSIONS

These findings help validate event-free survival as a clinically meaningful end point and strong predictor for overall survival and highlight the need for additional novel therapies that may delay or prevent recurrence in resectable stage II and III non-small cell lung cancer.

Genomic Landscape of Advanced Solid Tumors in Middle East and North Africa Using Circulating Tumor DNA in Routine Clinical Practice

INTRODUCTION

Next-generation sequencing (NGS) of tumor DNA can detect actionable drivers and help guide therapy for patients with advanced-stage cancers. While tissue-based genotyping is considered a standard of care, blood-based genotyping is emerging as a valid alternative. Tumor genomic profiles may vary by region, and data from the Middle East and North Africa (MENA) are not widely available. This study elucidates the genomic landscape of advanced solid cancers in patients from the MENA region by retrospectively analyzing results from NGS circulating tumor DNA (ctDNA) testing.

METHODS

In routine clinical practice, 926 plasma samples from 767 patients with advanced cancers from the MENA region were profiled using a comprehensive NGS assay (Guardant360®). We conducted a pan-cancer analysis and sub-analyses focusing on lung, breast, and colorectal cancers.

RESULTS

In the pan-cancer group, TP53 (58.5%), EGFR (20.4%), and KRAS (18.9%) were the most frequently mutated genes. EGFR (10.2%), FGFR1 (4.9%), and PIK3CA (4.9%) showed the most amplifications, while fusions were observed in 2.7% of patients, including ALK, FGFR2, and RET. For lung adenocarcinoma, EGFR (30.5%), KRAS (19.3%), and ERBB2 (4.6%) were the most frequently identified alterations among the genes recommended for evaluation by the National Comprehensive Cancer Network (NCCN). In patients with breast cancer, PIK3CA (35.3%), ESR1 (21.7%), and BRCA1/2 (13.3%) had the most prevalent alterations among NCCN-recommended genes. In colorectal cancer, KRAS (39.0%), NRAS (8.0%), and BRAF (V600E, 4.0%) were the most observed mutations among genes recommended by the NCCN. Comparing this cohort to publicly available Western and Eastern datasets also indicated similarities (including PIK3CA in breast cancer) and variances (including EGFR in lung adenocarcinoma) in key genes of interest in the analyzed cancer types.

CONCLUSION

Overall, our findings provide insight into the genomic landscape of individuals with advanced solid organ malignancies from the MENA region and support the role of ctDNA in guiding therapeutic decisions.

Driver gene alterations in NSCLC patients in southern China and their correlation with clinicopathologic characteristics

Introduction

In this study, we aimed to explore the relationship between clinicopathological features and driver gene changes in Chinese NSCLC patients.

Methods

Amplification refractory mutation system PCR was used to detect the aberrations of 10 driver oncogenes in 851 Chinese NSCLC patients, and their correlation with clinicopathological characteristics was also analyzed. Moreover, three models of logistic regression were used to analyze the association between histopathology and EGFR or KRAS mutations.

Results

The top two most frequently aberrant target oncogenes were EGFR (48.06%) and KRAS (9.51%). These were followed by ALK (5.41%), HER2 (2.35%), MET (2.23%), RET (2.11%), ROS1 (1.88%), BRAF (0.47%), NRAS (0.24%), and PIK3CA (0.12%). Additionally, 11 (1.29%) patients had synchronous gene alterations in two genes. The main EGFR mutations were exon 21 L858R and exon 19-Del, which accounted for 45.97% and 42.79% of all EGFR mutations, respectively. Logistic regression analysis showed that the frequency of EGFR mutations was positively correlated with women, non-smokers, lung adenocarcinoma, and invasive non-mucinous adenocarcinoma (IA), and negatively correlated with solid nodule, micro-invasive adenocarcinoma, and solid-predominant adenocarcinoma. KRAS mutations were positively associated with men and longer tumor long diameters and negatively correlated with lung adenocarcinoma (P < 0.05 for all).

Conclusion

Our findings suggest that the EGFR mutation frequency was higher in women, non-smokers, lung adenocarcinoma, and the IA subtype in lung adenocarcinoma patients, while the KRAS mutation rate was higher in men and patients with longer tumor long diameter and lower in lung adenocarcinoma patients.

Development and validation of a novel high-performance liquid chromatography (HPLC) method for the detection of related substances of pralsetinib, a new anti-lung cancer drug

Background

Pralsetinib, a targeted inhibitor of the RET enzyme, plays a critical role in the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) characterized by RET gene fusion mutations following platinum-based chemotherapy. Nevertheless, impurities resulting from the manufacturing and degradation of pralsetinib have the potential to impact its therapeutic effectiveness and safety profile.

Methods

To address this issue, a liquid chromatography method was developed and validated for the specific identification of pralsetinib and its related impurities. The separation of pralsetinib and its related impurities was achieved via a Waters X Bridge C18 column with dimensions of 4.6 mm × 250 mm and a particle size of 5 μm. Mobile phase A was composed of 20 mmol/L potassium dihydrogen phosphate (KH2PO4) and acetonitrile (ACN) at a volume ratio of 19:1, while mobile phase B consisted solely of ACN, utilizing a gradient elution technique. Detection was performed at a wavelength of 260 nm, with an injection volume of 10 μL and a flow rate of 1.0 mL/min.

Results

The chromatographic method established in this study was validated according to the ICH Q2 (R1) guidelines. The method demonstrated excellent linearity over a specific concentration range (imp-A: 0.035-10.21 μg/mL; imp-B: 0.09-10.16 μg/mL; imp-C: 0.15-10.19 μg/mL; pralsetinib: 0.04-10.32 μg/mL). Additionally, the method possesses high sensitivity, with detection limits for impurities A, B, C, and pralsetinib of 0.01, 0.03, 0.015, and 0.013 μg/mL, respectively, and quantification limits of 0.035, 0.09, 0.05, and 0.04 μg/mL, respectively. In terms of specificity, stability, repeatability, accuracy, and robustness, the method met the validation acceptance criteria. Overall, the chromatographic technique established in this study can effectively separate pralsetinib and its impurities, providing reliable assurance for the accurate detection and quantification of impurities.

Conclusion

The chromatographic method developed in this study can be utilized for the detection of pralsetinib and its impurities, offering a crucial reference for research on the quality of pralsetinib.

Beyond tobacco: genomic disparities in lung cancer between smokers and never-smokers

BACKGROUND

Tobacco use is one of the main risk factors for Lung Cancer (LC) development. However, about 10-20% of those diagnosed with the disease are never-smokers. For Non-Small Cell Lung Cancer (NSCLC) there are clear differences in both the clinical presentation and the tumor genomic profiles between smokers and never-smokers. For example, the Lung Adenocarcinoma (LUAD) histological subtype in never-smokers is predominately found in young women of European, North American, and Asian descent. While the clinical presentation and tumor genomic profiles of smokers have been widely examined, never-smokers are usually underrepresented, especially those of a Latin American (LA) background. In this work, we characterize, for the first time, the difference in the genomic profiles between smokers and never-smokers LC patients from Chile.

METHODS

We conduct a comparison by smoking status in the frequencies of genomic alterations (GAs) including somatic mutations and structural variants (fusions) in a total of 10 clinically relevant genes, including the eight most common actionable genes for LC (EGFR, KRAS, ALK, MET, BRAF, RET, ERBB2, and ROS1) and two established driver genes for malignancies other than LC (PIK3CA and MAP2K1). Study participants were grouped as either smokers (current and former, n = 473) or never-smokers (n = 200) according to self-report tobacco use at enrollment.

RESULTS

Our findings indicate a higher overall GA frequency for never-smokers compared to smokers (58 vs. 45.7, p-value < 0.01) with the genes EGFR, KRAS, and PIK3CA displaying the highest prevalence while ERBB2, RET, and ROS1 the lowest. Never-smokers present higher frequencies in seven out of the 10 genes; however, smokers harbor a more complex genomic profile. The clearest differences between groups are seen for EGFR (15.6 vs. 21.5, p-value: < 0.01), PIK3CA (6.8 vs 9.5) and ALK (3.2 vs 7.5) in favor of never-smokers, and KRAS (16.3 vs. 11.5) and MAP2K1 (6.6 vs. 3.5) in favor of smokers. Alterations in these genes are comprised almost exclusively by somatic mutations in EGFR and mainly by fusions in ALK, and only by mutations in PIK3CA, KRAS and MAP2K1.

CONCLUSIONS

We found clear differences in the genomic landscape by smoking status in LUAD patients from Chile, with potential implications for clinical management in these limited-resource settings.

Beyond Hormones: Investigating the Impact of Progesterone Receptor Membrane Component 1 in Lung Adenocarcinoma

Progesterone Receptor Membrane Component 1 (PGRMC1) is a candidate oncogene with a prominent involvement in the pathogenesis of diverse cancers (ovarian, thyroid, breast, colon, head, and neck). Our study ascertains the ability of PGRMC1 to influence WNT members in the non-small cell lung cancer subtype-lung adenocarcinoma (LUAD) and participates in augmented cell proliferation and migration. Both computational and in vitro experimental analyses were performed in this study. Gene silencing, in vitro assays, gene expression & and protein expression studies were performed to ascertain the role of PGRMC1 in LUAD cells. The computational analysis, PGRMC1 gene level expression was analysed using the microarray gene expression omnibus datasets (GSE27262; GSE18842) to compare LUAD tumours and normal tissues. Concurrently, the gene expression profiling interactive analysis of PGRMC1 and Kaplan-Meier survival analysis revealed a decreasing patient survival rate with an increasing PGRMC1 gene expression in LUAD tumour samples. Interestingly, the experimental gene silencing studies were conducted in vitro (si-PGRMC1 Vs si-Control) to understand the essential role of PGRMC1 in regulating WNT-associated genes (WNT1, WNT5A, and WNT11). Comparative experimental cell migration and spheroid formation assays (si-PGRMC1 Vs si-Control) in vitro showed a strong association between PGRMC1 and LUAD. In vitro expression analysis using real-time PCR and western blot further confirmed the connecting link between PGRMC1 and WNT5A compared to other WNT member genes (WNT1 and WNT11) in LUAD. The computational and experimental analyses agreed with one another.

Concordance of Immunohistochemistry and Fluorescence In Situ Hybridization in the Detection of Anaplastic Lymphoma Kinase (ALK) and Ros Proto-oncogene 1 (ROS1) Gene Rearrangements in Non-Small Cell Lung Carcinoma: A 4.5-Year Experience Highlighting Challenges and Pitfalls

CONTEXT.—

ALK and ROS1 rearrangements are essential biomarkers to be tested in advanced lung adenocarcinomas. While D5F3 Ventana assay is a companion diagnostic for anaplastic lymphoma kinase-targeted therapy, immunohistochemistry is only a screening tool for detecting ROS1 rearrangement. Confirmation by cytogenetic or molecular techniques is necessary.

OBJECTIVE.—

To evaluate the utility of ALK and ROS1 fluorescence in situ hybridization as a complement to immunohistochemistry in routine predictive biomarker testing algorithms.

DESIGN.—

The study was ambispective, spanning 4.5 years during which lung adenocarcinoma samples were subjected to EGFR mutation testing by real-time polymerase chain reaction and ALK/ROS1 rearrangement testing by immunohistochemistry (Ventana D5F3 assay for anaplastic lymphoma kinase protein; manual assay with D4D6 clone for Ros proto-oncogene 1 protein). Fluorescence in situ hybridization was performed in all anaplastic lymphoma kinase equivocal and Ros proto-oncogene 1 immunopositive cases.

RESULTS.—

Of 1874 samples included, EGFR mutations were detected in 27% (481 of 1796). Anaplastic lymphoma kinase immunohistochemistry was positive in 10% (174 of 1719) and equivocal in 3% (58 of 1719) of samples tested. ALK fluorescence in situ hybridization showed 81% (77 of 95) concordance with immunohistochemistry. Ros proto-oncogene 1 immunopositivity was noted in 13% (190 of 1425) of cases, with hybridization-confirmed rearrangements in 19.3% (26 of 135) of samples, all of which showed diffuse, strong- to moderate-intensity, cytoplasmic staining in tumor cells. Ros proto-oncogene 1 protein overexpression without rearrangement was significantly common in EGFR-mutant and ALK-rearranged adenocarcinomas.

CONCLUSIONS.—

Immunostaining is a robust method for ALK-rearrangement testing, with fluorescence in situ hybridization adding value in the rare equivocal stained case. ROS1-rearrangement testing is more cost-effective if immunohistochemistry is followed by fluorescence in situ hybridization after excluding EGFR-mutant and ALK-rearranged adenocarcinomas.

Co-Occurring Driver Genomic Alterations in Advanced Non-Small-Cell Lung Cancer (NSCLC): A Retrospective Analysis

Background: Actionable driver mutations account for 40-50% of NSCLC cases, and their identification clearly affects treatment choices and outcomes. Conversely, non-actionable mutations are genetic alterations that do not currently have established treatment implications. Among co-occurring alterations, the identification of concurrent actionable genomic alterations is a rare event, potentially impacting prognosis and treatment outcomes. Methods: We retrospectively evaluated the prevalence and patterns of concurrent driver genomic alterations in a large series of NSCLCs to investigate their association with clinicopathological characteristics, to assess the prognosis of patients whose tumor harbors concurrent alterations in the genes of interest and to explore their potential therapeutic implications. Results: Co-occurring driver alterations were identified in 26 out of 1520 patients with at least one gene alteration (1.7%). Within these cases, the incidence of concurrent actionable gene alterations was 39% (0.7% of the overall cohort). Among compound actionable gene mutations, EGFR was the most frequently involved gene (70%). The most frequent association was EGFR mutations with ROS1 rearrangement. Front-line targeted treatments were the preferred approach in patients with compound actionable mutations, with dismal median PFS observed (6 months). Conclusions: Advances in genomic profiling technologies are facilitating the identification of concurrent mutations. In patients with concurrent actionable gene alterations, integrated molecular and clinical data should be used to guide treatment decisions, always considering rebiopsy at the moment of disease progression.