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

Outcomes of Pembrolizumab plus chemotherapy for patients with metastatic non-squamous NSCLC: Real-world evidence

BACKGROUND

Pembrolizumab with chemotherapy (immunochemotherapy) has shown encouraging overall survival (OS) benefits in non-squamous mNSCLC, as demonstrated by the KEYNOTE-189 trial. However, randomised controlled trials may not fully capture the diversity of real-world patients. This study aims to evaluate immunochemotherapy outcomes in a real-world setting, including subgroups underrepresented in the KEYNOTE-189 trial.

METHODS

Patients diagnosed with non-squamous mNSCLC 2011-2022 and recorded in Cancer Registry Database of the German Federal State Baden-Württemberg (BWCR), were analysed. OS was assessed using Kaplan-Meier and multivariable Cox models, adjusted for major clinical parameters. Results were compared with KEYNOTE-189.

RESULTS

Among 2630 eligible cases, 1314 patients received chemotherapy alone and 1316 received immunochemotherapy. Median OS (mOS) was 14.1 months (95%CI: 13.1-15.4) for immunochemotherapy and 10.4 months (95%CI: 9.7-11.2) for chemotherapy alone, with an HR of 0.7 (95%CI: 0.64-0.77). A significant benefit was seen in M1c stage (HR 0.7, 95%CI: 0.63-0.79). No significant OS improvement was observed in patients with ECOG 2-3 or bone metastases.

CONCLUSION

This real-world evidence suggests that immunochemotherapy generally improves OS in mNSCLC. Subgroup analysis showed no survival benefit for patients with ECOG >1 or bone metastasis, but a benefit for patients with M1c stage.

First-line treatments for KRAS-mutant non-small cell lung cancer: current state and future perspectives

KRAS mutations are common in non-small cell lung cancer (NSCLC) and are associated with patient prognosis; however, targeting KRAS has faced various difficulties. Currently, immunotherapy, chemotherapy, and chemoimmunotherapy play pivotal roles in the first-line treatment of KRAS-mutated NSCLC. Here, we summarize the current evidence on first-line therapies and compare the treatment outcomes and biomarkers for different regimens. KRAS inhibitors and other emerging alternative treatments are also discussed, as combining these drugs with immunotherapy may serve as a promising first-line treatment for KRAS-mutated NSCLC in the future. We hope that this review will assist in first-line treatment choices and shed light on the development of novel agents for KRAS-mutated NSCLC.

Pooled analysis of oral vinorelbine as single agents in patients with advanced NSCLC

OBJECTIVES

This was a pooled analysis of data from weekly vinorelbine (VNR) treatment arms of four individual open-label, phase II studies to assess and refine the efficacy and tolerance of weekly oral VNR in a larger cohort of patients with advanced NSCLC.

MATERIALS AND METHODS

All patients included in this pooled analysis received oral VNR at the dose of 60 mg/m2 weekly at cycle 1 (3-week cycle), followed by an increase to 80 mg/m2 weekly for subsequent cycles until disease progression or toxicity. Efficacy was based on objective response rate (ORR), progression-free survival (PFS), and disease control rate (DCR).

RESULTS

A total of 247 patients were included. The ORR and DCR were 8.9% and 57.5% respectively, median PFS and OS were 3.3 and 8.5 months, respectively. Less than half (40.7%) of patients reported ≥1 serious AE (regardless of causality), with 12.3% reporting ≥1 treatment-related serious AE (grade ≥3: 11.1%). The most reported grade ≥3 AEs were neutropenia (17.6%), fatigue (5.8%), and decreased appetite (4.9%).

CONCLUSION

This pooled analysis showed that weekly oral VRN is a valid option, with an acceptable safety profile, in this population of patients with advanced NSCLC, confirming results from previous individual studies.

Applied first-line systemic treatments, treatment modifications and outcomes in non-oncogenic metastatic non-small cell lung cancer in the Netherlands in 2019-2020: A nationwide study

BACKGROUND

The treatment landscape for patients with metastatic non-small cell lung cancer (mNSCLC) is rapidly evolving as new therapies are continually introduced. This study aimed to provide a contemporary overview of how patients diagnosed with mNSCLC in the Netherlands are treated in routine clinical practice, how applied systemic treatments are tolerated and with which overall survival (OS).

METHODS

This nationwide retrospective study utilised data from the Netherlands Cancer Registry (NCR) complemented by electronic health records data of patients diagnosed with stage IV non-oncogenic mNSCLC in the years 2019-2020. First-line (1 L) treatments and corresponding overall survival (OS) were identified and compared across hospital types (academic, teaching, general), along with a multivariable analysis of 1 L treatment, patient, and tumour characteristics. In a subset of seven teaching hospitals, dose adjustments, early discontinuations and follow-up treatments were also assessed together with ESMO guideline adherence based on ECOG scores and levels of PD-L1 tumour expression.

RESULTS

The total sample comprised 9511 patients (56 % male and mean age 68 years) of which 4485 (47 %) received best supportive care (BSC) only. The most frequently applied 1 L systemic treatment was chemo-immunotherapy with 51 % one-year survival. Starting any 1 L systemic treatment was more frequent among patients with younger age, better performance status, PD-L1 > 50 %, and those with their diagnosis established in an academic hospital. Chemotherapy was discontinued early (<4 cycles) in 46 % of patients with 1 L chemotherapy and 34 % of patients with chemo-immunotherapy. Guideline adherence was highest in patients with ECOG1 and PD-L1 1-49 % (76 %) and lowest in the ECOG > = 2 and PD-L1 1-49 % group (30 %).

CONCLUSIONS

Best supportive care over systemic treatment and chemotherapy treatment modifications are common in patients with mNSCLC. Presenting information to patients about these outcomes can support shared-decision making.

Population Pharmacokinetics of Osimertinib in Patients With Non-Small Cell Lung Cancer

Population pharmacokinetics (popPK) modeling for osimertinib, a third-generation, irreversible, oral epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) that potently and selectively inhibits both EGFR-TKI sensitizing mutations and EGFR T790M, was previously reported utilizing AURA and AURA2 data (advanced non-small cell lung cancer [NSCLC]). We report updated popPK modeling incorporating AURA3 and FLAURA data (advanced NSCLC); model validation used ADAURA data (resected stage IB-IIIA NSCLC). Updated popPK analyses were based on patients from AURA (n = 599), AURA2 (n = 210), AURA3 (n = 277), and FLAURA (n = 278) using a linear one-compartmental disposition model for osimertinib and its metabolite, AZ5104, with first-order oral absorption. A full covariate model, using Monte Carlo simulations, was developed to assess the effects of covariates on osimertinib and AZ5104 clearance. External validation was conducted using ADAURA study data (n = 325). In the final popPK model, the apparent clearance and volume of distribution of osimertinib (14.3 L/h; 918 L) and AZ5104 (31.3 L/h; 143 L) were comparable to previous analyses. Albumin levels and body weight influenced osimertinib PK, but the effects were not considered clinically meaningful; other covariates had no impact on PK. Goodness-of-fit plots indicated that the model adequately described all data. Visual predictive checks showed that the final model validated osimertinib steady-state PK for adjuvant treatment. PopPK modeling indicated that osimertinib dose adjustment is not required for patients' age, sex, body weight, race, smoking status, or line of therapy, confirming that a fixed 80 mg once-daily dose is optimal for osimertinib.

A prospective study on clinicians' attitudes and survival outcomes for patients with advanced NSCLC and poor performance status in the immunotherapy era: PICASO (GOIRC-04-2020)

BACKGROUND

Therapeutic strategies for patients with advanced NSCLC and an ECOG performance status (PS) 2 at diagnosis are supported by limited evidence.

PATIENTS AND METHODS

We led a prospective, observational study in 20 Italian centers on patients with advanced NSCLC and ECOG PS 2. Patients with EGFR mutations, ALK fusions or receiving first-line targeted treatments were excluded. We recorded physicians' attitudes in addressing first-line treatments and clinical outcomes. The primary endpoint was progression-free rate at six months.

RESULTS

From March 2022 to October 2023, 198 consecutive patients were included. Median age was 73 years (range 43-91). Forty-four patients (22%) were candidate to best supportive care, 49 (25%) to single agent chemotherapy, 14 (7%) to platinum doublet, 40 (20%) to mono-immunotherapy, 52 (26%) to chemo-immunotherapy. At a median follow-up of 9.4 months (95 % CI 7.2 - 11.7), 6-month progression-free rate was 15.3%, with a median progression-free survival of 1.6 months (95 % CI 1.3 - 1.9). Six-months overall survival (OS) rate was 27.7%, with a median OS of 2.8 months (95 % CI 2.0 - 3.6). Patients receiving chemo-immunotherapy (PD-L1 < 50%) had 6-month progression-free and OS rates of 22.9% and 29.1% respectively, with median PFS 1.9 months and median OS 3.7 months; mono-immunotherapy for patients with PD-L1 ≥ 50% led to slightly better outcomes. Among 155 patients receiving active treatment, no clinical-pathological characteristic harbored a prognostic role. One third of patients receiving immunotherapy-containing regimens encountered early clinical progression or death before the first radiological evaluation. No relevant safety signals emerged across treatments.

CONCLUSIONS

Less than half of patients with NSCLC and ECOG PS 2 were candidates to the regimens recommended for fit pts, i.e. mono-immunotherapy or chemo-immunotherapy according to PD-L1. Even with immunotherapy, most of these patients have dismal outcomes, suggesting that trials dedicating to PS 2 perform an intrinsic patient selection.

Dealing with KRAS G12C inhibition in non-small cell lung cancer (NSCLC) - biology, clinical results and future directions

KRAS G12C mutation occurs in ∼ 14 % of non-small cell lung cancer (NSCLC) patients and has been historically deemed undruggable, with immune-checkpoint inhibitors (ICIs) and platinum-based chemotherapy (PBC) representing the standard-of-care in the advanced setting. First-in-class, covalent KRAS G12C OFF-inhibitors sotorasib and adagrasib have revolutionized the therapeutic landscape and recently entered clinical practice. However, limited efficacy alongside toxicity profiles strengthen the need to design novel molecules and to optimize therapeutic strategies to address and overcome intrinsic and acquired resistance mechanisms. Moreover, KRAS G12C frequently co-occurs with STK11/KEAP1 mutations, that represent a negative prognostic factor, being associated with increased metastatic potential and reduced overall survival and poorer outcomes with ICIs. Furthermore, the high incidence of brain metastases is common in KRAS G12C-mutant NSCLC, and the efficacy of standard therapies and KRAS G12C inhibitors in treating or preventing central nervous system involvement is still suboptimal. In this context, novel inhibitors, such as broad-spectrum inhibitors targeting the active GTP-bound ON-state, pan-RAS ON inhibitors and allele-selective tricomplex inhibitors, have showed promising early clinical activity although their clinical utility needs to be further elucidated. In addition, targeting upstream, downstream and parallel signaling pathways through combination strategies might enhance the activity of KRAS G12C inhibitors and eventually improve clinical outcomes in this subset of NSCLC patients. Several combinations are currently under clinical investigation and promising approaches include combinations of KRAS G12C inhibitors with ICIs, SOS1, SHP2 inhibitors and PBC. Notwithstanding the potential improved efficacy of combination strategies, tolerability remains a critical challenge that must be carefully assessed and managed.

Narciclasine enhances cisplatin-induced apoptotic cell death by inducing unfolded protein response-mediated regulation of NOXA and MCL1

BACKGROUND

Platinum-based chemotherapy is commonly used to treat non-small cell lung cancer (NSCLC); however, innate and acquired resistance is clinically seen in many patients. Hence, a combinatorial approach with novel therapeutic agents to overcome chemoresistance is a promising option for improving patient outcomes. We investigated the combinational anticancer efficacy of cisplatin and narciclasine in three-dimensional NSCLC tumor spheroids.

METHODS

To assess the efficacy of cisplatin and narciclasine, cell viability assays, live/dead cell staining, cell death enzyme-linked immunosorbent assay (ELISA), western blot analysis for proteins related to apoptosis, and in vivo xenograft experiments were performed. The synergistic effects of cisplatin and narciclasine were elucidated through transcriptomic analysis and subsequent validation of candidate molecules by regulating their expression. To clarify the underlying molecular mechanisms, the activation of unfolded protein responses and kinetics of a candidate protein were assessed.

RESULTS

Narciclasine inhibited viability of NSCLC tumor spheroids and augmented the sensitivity of cisplatin-resistant tumor spheroids to cisplatin by inducing apoptosis. After conducting bioinformatic analysis using RNA sequencing data and functional validation experiments, we identified NOXA as a key gene responsible for the enhanced apoptosis observed with the combination of cisplatin and narciclasine. This treatment dramatically increased NOXA while downregulating anti-apoptotic MCL1 levels. Silencing NOXA reversed the enhanced apoptosis and restored MCL1 levels, while MCL1 overexpression protected tumor spheroids from combination treatment-induced apoptosis. Interestingly, narciclasine alone and in combination with cisplatin induced unfolded protein response and inhibited general protein synthesis. Furthermore, the combination treatment increased NOXA expression through the IRE1α-JNK/p38 axis and the activation of p53. Cisplatin alone and in combination with narciclasine destabilized MCL1 via NOXA-mediated proteasomal degradation.

CONCLUSIONS

We identified a natural product, narciclasine, that synergizes with cisplatin. The combination of cisplatin and narciclasine induced NOXA expression, downregulated MCL1, and ultimately induced apoptosis in NSCLC tumor spheroids. Our findings suggest that narciclasine is a potential natural product for combination with cisplatin for treatment of NSCLC.

Safety and efficacy of rechallenge with immune checkpoint inhibitors and anlotinib in advanced non-small cell lung cancer without targetable driver mutations: a retrospective analysis

OBJECTIVE

This study assessed the safety and efficacy of rechallenging patients in advanced non-small cell lung cancer (NSCLC) without targetable driver mutations using a combination of immune checkpoint inhibitors (ICIs) and anlotinib following progression after prior immunotherapy.

METHODS

A retrospective analysis was performed on 14 patients who received rechallenge with ICIs combined with anlotinib at the First Affiliated Hospital of Guangzhou University of Chinese Medicine. China, between March 2020 and June 2024.

RESULTS

The study observed an objective response rate of 28.6% and a disease control rate of 92.9%. The median progression-free survival (PFS) was 11.7 months, with programmed death-ligand 1 (PD-L1)-positive patients demonstrating significantly longer PFS (13.0 months) compared with PD-L1-negative or unknown patients (10.3 months, P = 0.048). Toxicity was manageable, with most adverse events being mild to moderate in severity. Only one case (7.1%) of grade 3 adverse events was reported, and no treatment-related fatalities occurred.

CONCLUSION

ICIs combined with anlotinib as a rechallenge therapy exhibited promising efficacy and an acceptable safety profile in patients with advanced NSCLC without targetable driver mutations. These findings suggest a potential treatment option for patients with post-immunotherapy progression.

Xevinapant plus avelumab in advanced solid tumours, with a dose expansion in advanced non-small-cell lung cancer: exploratory biomarker, safety and efficacy analyses from an open-label, nonrandomised phase Ib study

Background

Xevinapant, an inhibitor of apoptosis protein (IAP) inhibitor, has shown promising activity in combination with anticancer agents, including radiotherapy, and, in preclinical studies, anti-PD-(L)1 antibodies. This, in part, is due to its ability to restore apoptosis and increase antitumour immunity.

Objectives

We report efficacy, safety and exploratory biomarker analyses of xevinapant plus avelumab (anti-PD-L1) in a two-part, open-label, nonrandomised, phase Ib study.

Design

Part A assessed patients with advanced solid tumours who received xevinapant (100, 150, 200 or 250 mg/day, with no random allocation, on Days 1-10 and 15-24) in combination with avelumab (10 mg/kg) on Days 1 and 15 in 28-day cycle. Part B assessed patients with advanced non-small-cell lung cancer (NSCLC) who received xevinapant at the recommended phase II dose (RP2D) plus avelumab (maximum 26 cycles).

Methods

Part A assessed the safety and tolerability of the combination and established the maximum tolerated dose (MTD) and RP2D of xevinapant. Part B assessed the antitumour activity of xevinapant at the RP2D combined with avelumab compared with a historical control (avelumab alone). Exploratory biomarker analyses were also conducted.

Results

In part A (n = 16), xevinapant 200 mg/day was established as the RP2D with avelumab and the MTD was not reached. The most common treatment-emergent adverse events (TEAEs) irrespective of xevinapant dose were nausea and fatigue (n = 11 (68.8%) each). In part B (n = 38; four patients received prior anti-PD-(L)1 antibody), the objective response rate (ORR) was 10.5% (95% confidence interval (CI), 2.9-24.8; partial response, n = 4) and the most common TEAE was decreased appetite (n = 13 (34.2%)). Levels of plasma IL-10, IL-1β, IL-13 and CD8+ T cells increased during the study, and circulating levels of CD4+ T cells and Tregs increased during cycle 1. Macrophage-related gene expression signatures increased in patients with a partial response or stable disease. Low baseline Ki-67 expression in tumour samples correlated with a partial response.

Conclusion

The RP2D of xevinapant with avelumab was established; however, the ORR was not superior to the historical control (avelumab alone). The combination had a manageable safety profile in both study parts. Biomarker analyses provide insights into drivers associated with efficacy in patients with NSCLC receiving xevinapant plus avelumab.

Trial registration

NCT03270176 (https://clinicaltrials.gov/study/NCT03270176). Registered on ClinicalTrials.gov on 29 August 2017.

Durvalumab with or without tremelimumab in combination with chemotherapy in first-line metastatic non-small-cell lung cancer: outcomes by tumor mutational burden in POSEIDON

BACKGROUND

In updated analyses from the phase III POSEIDON study, after a median follow-up of >5 years, tremelimumab plus durvalumab and chemotherapy (T + D + CT) showed durable long-term overall survival (OS) benefit versus CT alone in first-line metastatic non-small-cell lung cancer (mNSCLC). In this article, we report the associations of tumor mutational burden (TMB) with outcomes of D with or without T in combination with CT versus CT alone.

PATIENTS AND METHODS

A total of 1013 patients with EGFR/ALK wild-type mNSCLC were randomized (1 : 1 : 1) to T + D + CT, D + CT, or CT, stratified by programmed cell death-ligand 1 (PD-L1) tumor cell (TC) expression ≥50% versus <50%, disease stage (IVA versus IVB) and histology (squamous versus nonsquamous). Patient subgroups were defined by a range of blood TMB (bTMB) values, including at a prespecified cut-off of 20 mutations (mut)/megabase (Mb) and across further subdivisions by PD-L1 TC expression ≥1% or <1% and by tissue TMB (tTMB) values.

RESULTS

At the primary OS data cut-off (12 March 2021), at each bTMB or tTMB cut-off, the magnitude of OS benefit appeared greater among patients in the bTMB- or tTMB-high subgroups for the T + D + CT arm versus the CT arm but was similar between subgroups for the D + CT arm versus the CT arm. Updated OS analyses in the bTMB ≥20 and <20 mut/Mb subgroups, after median follow-up of >5 years (data cut-off 24 August 2023), were similar to those obtained at the primary OS data cut-off.

CONCLUSIONS

First-line treatment with T (limited course) plus D (until progression) and four cycles of CT consistently improved clinical outcomes versus CT alone in both bTMB-high and -low subgroups, and also in both high and low tTMB subgroups, in patients with mNSCLC. Benefit appeared greater in the TMB-high versus TMB-low subgroups; the addition of anti-cytotoxic T lymphocyte-associated antigen-4 to anti-PD-L1 and CT seemed to increase the magnitude of this difference.

Equalizing prognostic disparities in KRAS-mutated stage III NSCLC patients: addition of durvalumab to combined chemoradiotherapy improves survival

INTRODUCTION

Stage III non-small cell lung cancer (NSCLC) is a heterogeneous group and identification of subgroups with differential treatment responses is crucial. Addition of durvalumab to concurrent chemoradiotherapy (cCRT) has previously been shown to improve survival outcomes. Meanwhile, subgroups harboring KRAS mutations have been shown to have worse prognosis. We investigated whether KRAS mutational status may affect survival outcomes after adjuvant durvalumab following cCRT in stage III NSCLC.

METHODS

In this multi-center retrospective study, we present a real-world dataset of all stage III NSCLC patients treated with curative-intent cCRT with molecular assessment, between 2016 and 2021 in the Västra Götaland Region of western Sweden. The study period includes the standard practice prior to the introduction of durvalumab, enabling evaluation of the potential impact of immune checkpoint blockade (ICB). Primary study outcomes were overall survival (OS) and progression free survival (PFS).

RESULTS

We identified 145 patients who received cCRT with curative intent, and 32 % harbored an activating mutation in the KRAS gene (KRASMUT; n = 46). Compared to patients with wild-type KRAS (KRASWT; n = 99), KRASMUT had worse OS (p = 0.047) and PFS (p = 0.038). This finding persisted on multivariate analysis with OS (HR 1.703, 95 % CI 1.074-2.702, p = 0.024) and PFS (HR 1.628, 95 % CI 1.081-2.453, p = 0.020). Within the subgroup that received cCRT alone, KRASMUT patients (n = 35) exhibited worse OS (p = 0.036) and PFS (p = 0.037) compared with KRASWT (n = 35). However, among those who received additional durvalumab after cCRT (KRASWT; n = 99. KRASMUT; n = 11) there were no significant differences in OS (0.788) or PFS (0.855) between the groups.

CONCLUSIONS

KRAS mutations are a negative prognostic factor after cCRT in stage III NSCLC, and the addition of durvalumab ameliorates the negative impact of harboring this mutation.

Recent advances in the use of liquid crystalline nanoparticles for non-small cell lung cancer treatment

INTRODUCTION

Non-small cell lung cancer (NSCLC) continues to pose a considerable health challenge with few therapeutic alternatives. Liquid crystalline nanoparticles (LCN) are nanostructured drug delivery systems made of lipid-based amphiphilic materials that self-assemble into crystalline phases in aqueous environments. LCN have become a promising way to treat NSCLC owing to their specific properties that make them useful for targeted delivery and controlled drug release.

AREAS COVERED

The review provides a brief overview of the use of LCN in the treatment of NSCLC. It explores their composition, fabrication methods, and characterization processes. The article further addresses several nanoparticle-based approaches for the treatment of NSCLC. Ultimately, it underscores the promise of LCNs as a promising drug delivery system for NSCLC and discusses the obstacles and outlook in this field.

EXPERT OPINION

LCN represents a promising frontier in the treatment of NSCLC, offering several specific advantages over conventional therapies. Utilizing their intrinsic self-assembly characteristics, LCN provides meticulous control over drug encapsulation, release kinetics, and cellular absorption, which are crucial for improving therapy success. LCN also has the capability for co-delivery of various drugs, facilitating synergistic therapeutic benefits and addressing multidrug resistance, a prevalent issue in NSCLC treatment.

Chemoradiotherapy efficacy in patients with stage III non-small cell lung cancer (NSCLC): A prognostic clinical and biomarker-based model

BACKGROUND

Chemoradiotherapy (CRT) followed by adjuvant durvalumab is the standard of care for fit patients with unresectable stage III non-small cell lung cancer (NSCLC). However, 20-25 % of the patients do not survive longer than 1 year after treatment initiation, i.e. receive futile treatment. We aimed to develop a prognostic model that can identify patients at high risk of early mortality during and after CRT.

METHODS

Patients with stage III NSCLC treated with CRT were included in the development- (N = 328; MAASTRO Biobank, 2004-2020, NCT01084785) and validation cohorts (N = 39; NCT02921854, NCT04432142). Both clinical parameters (age, sex, body mass index, performance status (PS), tumor stage (UICC 8), and sequence of chemotherapy administration) and peripheral immune-related biomarkers were included in the model development. Futile treatment was defined as death within one year after the first fraction of RT.

RESULTS

In the multivariable logistic regression analysis, PS ≥ 2 (OR = 2.89, 95 % CI 1.25-6.66, p = 0.013), stage IIIC (OR = 3.07, 95 % CI 3.07-6.9, p = 0.007), sequential chemotherapy (OR = 2.07, 95 % CI 1.19-3.62, p = 0.010), IL-6 (OR = 2.17, 95 % CI 1.27-3.70, p = 0.005), IP-10 (OR = 1.58, 95 % CI 0.92-2.73, p = 0.099), and soluble programmed death-ligand 1 (sPD-L1) (OR = 3.24, 95 % CI 1.90-5.54, p < 0.001) were identified as independent risk factors of early mortality. A nomogram was developed to calculate the risk of receiving futile treatment for each patient. The AUC of the development and validation cohort was 0.774 (95 % CI 0.716-0.832) and 0.734 (95 % CI 0.568-0.902), respectively. Patients classified as intermediate or high risk to receive futile treatment presented 23.7 % of the total cohort.

CONCLUSIONS

A prognostic model was developed that can identify patients who are at high risk of early mortality during and after CRT. These patients may be included in clinical trials aiming to improve their outcome.

Treatment of advanced‑stage non‑small cell lung cancer: Current progress and a glimpse into the future (Review)

Before the twentieth century, patients with advanced lung cancer had limited treatment options and chemotherapy was the primary form of treatment, with an overall survival often <0.5 years. However, with advances in society and medical technology, the treatment approaches for advanced non-small cell lung cancer (NSCLC) have markedly changed. Traditional chemotherapy has been gradually replaced by targeted therapy and immunotherapy, leading to the emergence of various new therapeutic options that offer patients more personalized and precise care. This raises the question of what the future holds for the treatment of NSCLC. This review provides a comprehensive analysis of the latest breakthroughs in targeted therapies, immunotherapies, and drugs for antibody-drug conjugates (ADCs), highlights advances in multimodal combination therapy strategies, and explores the causes of resistance and the challenges that exist in overcoming it. In particular, this review provides unique insights into key directions for future research in NSCLC, such as personalised treatment strategies and biomarker exploration based on multi-omics data, aiming to provide new inspiration for clinical decision-making and research.

Efficacy of immune checkpoint inhibitors rechallenge and metronomic cyclophosphamide with or without bevacizumab in metastatic nonsmall cell lung cancer

OBJECTIVE

The present study aims to evaluate the efficacy of immune checkpoint inhibitor (ICI) rechallenge in combination with metronomic cyclophosphamide, with or without bevacizumab, in patients with metastatic nonsmall cell lung cancer (NSCLC) and to investigate the clinical characteristics associated with the response to the therapy.

MATERIALS AND METHODS

The study included 43 patients with metastatic NSCLC who responded to ICIs for ≥4 months and subsequently experienced disease progression. The patients then underwent ICI rechallenge along with either oral cyclophosphamide daily alone (n = 24) or cyclophosphamide and bevacizumab (n = 19).

RESULTS

Combining ICI with cyclophosphamide resulted in an objective response rate (ORR) of 16.7%, disease control rate (DCR) of 75.0%, median progression-free survival (PFS) of 5.8 months, and overall survival (OS) of 15.4 months. Oral cyclophosphamide and bevacizumab cohort achieved an ORR of 26.3%, a DCR of 78.9%, a PFS of 6.8 months, and an OS of 17.6 months. No treatment-related adverse events resulted in the discontinuation of the study therapy in either cohort. Multivariate analysis demonstrated that the absence of an objective response to initial ICIs (OS: P = 0.016), poor Eastern Cooperative Oncology Group Performance Status (ECOG PS) (PFS: P = 0.017, OS: P = 0.032), and a neutrophil-to-lymphocyte ratio (NLR) ≥ 3.8 (PFS: P = 0.004, OS: P = 0.007) were negative predictors of rechallenge therapy.

CONCLUSION

The combination showed promising antitumor activity and a well-tolerated safety profile in patients with ICI-pretreated NSCLC. Furthermore, ECOG PS 0-1, objective response, and NLR ≤ 3.8 were predictive of the efficacy of the study therapy.

Real-world comparison of pembrolizumab alone and combined with chemotherapy in metastatic lung adenocarcinoma patients with PD-L1 expression ≥50

OBJECTIVES

The frontline treatment of metastatic lung adenocarcinoma with high Programmed death-ligand 1 (PD-L1) expression (≥50%) includes immune checkpoint inhibitors (ICIs) either as monotherapy or combined with chemotherapy. The added benefit of chemotherapy in this context lacks direct comparison in head-to-head trials. We aimed to compare these two ICI treatment modalities both overall and within relevant patient subgroups in a real-world setting.

MATERIALS AND METHODS

This retrospective, nationwide study included 410 individuals diagnosed in Norway during 2017 to 2021 with stage IV non-small-cell lung adenocarcinoma, PD-L1 expression ≥50%, and treated first line with the ICI pembrolizumab, either as monotherapy (n = 317) or in combination with platinum-based chemotherapy (n = 93). We analyzed early (6-month) and overall (3-year) risk of death after treatment initiation using Cox regression, adjusted for and stratified by sex, age, stage, PD-L1 expression, performance status, and education.

RESULTS

Patients treated with combination therapy had a higher median overall survival compared with monotherapy (22.6 months versus 14.2 months), and reduced risk of overall death, although not statistically significant after adjustment [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.54-1.00]. However, the risk of early death was significantly lower in patients receiving combination therapy, even after adjustment (HR 0.41, 95% CI 0.23-0.76). Across most subgroups, patients receiving combination therapy had comparable or superior survival outcomes relative to those receiving monotherapy. Particularly noteworthy were the observed benefits from combination therapy over monotherapy among females, individuals with stage IVB disease, and those with PD-L1 expression exceeding 75%.

CONCLUSION

Our real-world study demonstrates that combination therapy with ICI and chemotherapy provides superior early survival benefits over monotherapy in PD-L1-high patients. Additionally, certain subgroups showed enhanced overall survival. These findings challenge current treatment practices and underscore the need for further validation to optimize patient selection for monotherapy versus combination therapy, in particular to reassess the role of PD-L1 in treatment decisions.

The administration sequences of immune checkpoint inhibitors and chemotherapy cause discrete efficacy when treating non-small cell lung cancer: a retrospective study

Background

Immune checkpoint inhibitors (ICIs) combined with chemotherapy have become a standard first-line treatment for advanced non-small cell lung cancer (NSCLC). However, the optimal sequence of administrating the two treatments remains controversial.

Methods

This study included advanced NSCLC patients who received ICIs combined with chemotherapy at Renmin Hospital of Wuhan University and Xiangyang Hospital, Hubei University of Chinese Medicine between 1st September 2020 and 30th September 2024. Patients were categorized into the concurrent, immune-chemo, and chemo-immune groups based on different sequences of treatment administration. The primary endpoints evaluated were survival and treatment efficacy. The secondary endpoint assessed was treatment-related adverse events (TRAEs).

Results

This two-center, retrospective study included 270 NSCLC patients who received ICIs plus chemotherapy. Survival analysis revealed statistically significant differences across treatment groups. The median overall survival (mOS) durations were 636 days (concurrent group), 615 days (immune-chemo group), and 749 days (chemo-immune group), with a log-rank test demonstrating significant intergroup differences (P = 0.0017). Similarly, median progression-free survival (mPFS) showed distinct patterns at 178 days, 180 days, and 216 days for the respective groups (log-rank P = 0.0134). Additionally, the objective response rates (ORRs) for the three groups were 55.82% (72/129), 58.21% (39/67), and 68.92% (51/74), respectively. The incidence of TRAEs of any grade in the concurrent, the immune-chemo, and the chemo-immune groups was 77.52% (100/129), 65.67% (44/67), and 59.46% (44/74) rates, respectively, which was a significant difference (χ²=7.91, P=0.019). Despite patients experiencing Grade 3 or higher TRAEs had extremely poor prognoses, overall, patients who developed any grade of TRAEs had better survival outcomes, particularly those with skin or endocrine toxicity.

Conclusions

These findings suggest that the administration sequence of chemotherapy followed by ICIs may yield the greatest clinical benefit, providing a basis for clinical decision-making.

Impact of immune-related adverse event severity on overall survival in patients with advanced NSCLC receiving immune checkpoint inhibitors therapy, with a focus on combination regimens

BACKGROUND

Immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) may serve as prognostic markers in non-small cell lung cancer (NSCLC). While prior studies suggest differences in overall survival (OS) based on irAE, their prognostic impact across various ICI regimens remains underexplored.

METHODS

This retrospective study analyzed data from patients with advanced or recurrent NSCLC treated with ICIs between January 2018 and December 2022. Patients were categorized into three groups: severe irAEs (Grade 3-5), mild irAEs (Grade 1-2), and no-irAEs. OS was assessed across three regimens: anti-programmed cell death protein 1 (anti-PD-1) monotherapy, anti-PD-1/anti-programmed death-ligand 1 (anti-PD-L1) with chemotherapy (CT), and anti-PD-1 with anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4) ± CT.

RESULTS

Among the 256 patients included, 55 received anti-PD-1 monotherapy, 116 received anti-PD-1/L1 with CT, and 85 received anti-PD-1 with anti-CTLA-4 ± CT. For anti-PD-1 monotherapy, median OS (95 % confidence interval) was 38.3 (17.0-42.5) months in the mild irAE group, 16.1 (5.2-28.6) months in the severe irAE group, and 9.6 (12.3-37.1) months in the no-irAE group. In the anti-PD-1/L1 with CT group, median OS were 33.6 (14.2-40.3), 16.0 (1.84-not reached [NR]), and 17.7 (3.8-23.4) months, respectively. For anti-PD-1 with anti-CTLA-4 ± CT, median OS were 28.0 (21.8-NR), 10.9 (7.0-19.6), and 16.3 (8.7-23.4) months, respectively.

CONCLUSIONS

The relationship between irAE severity and OS was consistent across all ICI regimens, with patients experiencing mild irAEs demonstrating better OS across all ICI regimens.

Monitoring of the oncological process for lung cancer in Spain: an expert consensus report

INTRODUCTION

Continuous monitoring of the oncological process is essential for identifying inefficiencies and areas of improvement, enabling better resource allocation in the care of lung cancer patients.

OBJECTIVE

The objective is to define key indicators and identify critical variables for monitoring lung cancer care, aiming to improve early detection, reduce delays in diagnosis and treatment, and enhance biomarker research, ensuring timely and effective treatments for all patients.

METHODS

A multidisciplinary expert group conducted a consensus process based on a review of national guidelines and initiatives related to lung cancer care. The experts defined relevant indicators and identified variables for monitoring overall care, addressing delays, and improving biomarker research. The feasibility of incorporating these indicators into existing information systems was also assessed.

RESULTS

The proposed indicators provide a structured approach for assessing lung cancer care and outcomes. Their inclusion in healthcare information systems would improve the monitoring and evaluation of care quality and patient outcomes. Additionally, these indicators would also promote interoperability and continuous patient care across different centers and regions, allowing informed decision-making in the improvement of healthcare processes by those responsible for healthcare management.

CONCLUSIONS

The adoption of standardized indicators for lung cancer care monitoring can drive continuous improvement in healthcare processes. Implementing these indicators in information systems will enable better resource allocation, timely and effective treatment, and enhanced coordination among healthcare providers, ultimately improving patient outcomes.

Trends in Overall Survival in Lung Adenocarcinoma with EFGR Mutation, KRAS Mutation, or No Mutation

BACKGROUND

Treatment of lung adenocarcinoma has changed and now includes checkpoint inhibitors (CPIs) or, in the case of an EGFR mutation, third-generation EGFR TKI osimertinib. Few data compare the long-term overall survival (OS) of current and historic subgroups.

METHODS

This real-world analysis (KOMPASS study) included stage IV lung-adenocarcinoma patients with either EGFR, KRAS, or no mutation. Patients were assigned to the "current" EGFR, KRAS, or no-mutation cohort if they had mutation testing using NGS (n = 199; median date of diagnosis 2021). If they had an EGFR PCR test only, they were assigned to the "historic" EGFR or no-mutation cohort (n = 127; median date of diagnosis 2014).

RESULTS

Both the current and the historic EGFR cohorts had significantly longer OS than the respective no-mutation cohorts (HR 0.58 and 0.60, respectively). The current no-mutation and EGFR cohorts had a strong trend to longer OS than the respective historic cohorts. In the no-mutation cohorts, the improvement was due to an increase in long-term survivors (HR 0.71), whereas in the EGFR mutation cohorts, the median OS was improved without long-term survivors (HR 0.70). The KRAS cohort showed OS like the no-mutation cohort, with a plateau of long-term survivors around 20%.

CONCLUSIONS

A comparison of our data with that of the phase III trials KEYNOTE-189 and FLAURA suggests that the improved outcomes are due to the use of CPIs or osimertinib. The clinical trial results are well translated into real-world clinical practice with comparable OS. KRAS patients benefit from CPI treatment like no-mutation patients.

Genomics guiding personalized first-line immunotherapy response in lung and bladder tumors

BACKGROUND

Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment, particularly in advanced non-small cell lung cancer (NSCLC) and muscle-invasive bladder cancer (MIBC). However, identifying reliable predictive biomarkers for ICI response remains a significant challenge. In this study, we analyzed real-world cohorts of advanced NSCLC and MIBC patients treated with ICI as first-line therapy.

METHODS

Tumor samples underwent Whole Genome Sequencing (WGS) to identify specific somatic variants and assess tumor mutational burden (TMB). Additionally, mutational signature extraction and pathway enrichment analyses were performed to uncover the underlying mechanisms of ICI response. We also characterized HLA-I haplotypes and investigated LINE-1 retrotransposition.

RESULTS

Distinct mutation patterns were identified in patients who responded to treatment, suggesting potential biomarkers for predicting ICI effectiveness. In NSCLC, tumor mutational burden (TMB) did not differ significantly between responders and non-responders, while in MIBC, higher TMB was linked to better responses. Specific mutational signatures and HLA haplotypes were associated with ICI response in both cancers. Pathway analysis showed that NSCLC responders had active inflammatory and immune pathways, while pathways enriched in non-responders related to FGFR3 and neural crest differentiation, associated to resistance mechanisms. In MIBC, responders had alterations in DNA repair, leading to more neoantigens and a stronger ICI response. Importantly, for the first time, we found that LINE-1 activation was positively linked to ICI response, especially in MIBC.

CONCLUSION

These findings reveal promising biomarkers and mechanistic insights, offering a new perspective on predicting ICI response and opening up exciting possibilities for more personalized immunotherapy strategies in NSCLC and MIBC.

Opportunities for Precision Dosing of Cytotoxic Drugs in Non-Small Cell Lung Cancer: Bridging the Gap in Precision Medicine

Precision dosing of classical cytotoxic drugs in oncology remains underdeveloped, especially in treating non-small cell lung cancer (NSCLC). Despite advancements in targeted therapy and immunotherapy, classical cytotoxic agents continue to play a critical role in NSCLC treatment. However, the current body surface area (BSA)-based dosing of these agents fails to adequately address interindividual variability in pharmacokinetics. By better considering patient characteristics, treatment outcomes can be improved, reducing risks of under-exposure and over-exposure. This narrative review explores opportunities for precision dosing for key cytotoxic agents used in NSCLC treatment: cisplatin, carboplatin, pemetrexed, docetaxel, (nab-)paclitaxel, gemcitabine, and vinorelbine. A comprehensive review of regulatory reports and an extensive literature search were conducted to evaluate current dosing practices, pharmacokinetics, pharmacodynamics, and exposure-response relationships. Our findings highlight promising developments in precision dosing, although the number of directly implementable strategies remains limited. The most compelling evidence supports using the biomarker cystatin C for more precise carboplatin dosing and adopting weekly dosing schedules for docetaxel, paclitaxel, and nab-paclitaxel. Additionally, we recommend direct implementation of therapeutic drug monitoring (TDM)-guided dosing for paclitaxel. This review stresses the urgent need to reassess conventional dosing paradigms for classical cytotoxic agents to better align with the principles of the precision dosing framework. Our recommendations show the potential of precision dosing to improve NSCLC treatment, addressing gaps in the current dosing of classical cytotoxic drugs. Given the large NSCLC patient population, optimising the dosing of these agents could significantly improve treatment outcomes and reduce toxicity for many patients.

Use of immune checkpoint inhibitors in patients with lung cancer and multiple sclerosis

Non-small cell lung cancer (NSCLC) constitutes 80-85% of lung cancer cases and is a leading cause of cancer-related mortality. Most patients are diagnosed at metastatic stages, where curative treatment is rarely an option and the primary goal is to prolong survival while maintaining quality of life. Since NSCLC is often diagnosed in elderly individuals, comorbidities must also be considered in the treatment planning. Immune evasion is a central hallmark of cancer. By interactions between immune checkpoint molecules, such as programmed death 1 (PD-1) and its ligand PD-L1, as well as cytotoxic T-lymphocyte antigen 4 (CTLA-4), tumors downregulate immune responses, promoting self-tolerance and evading detection. Immune checkpoint inhibitors (ICIs) enhance the autoimmune function against cancer cells by blocking these targets and have wide evidence of efficacy in NSCLC. Currently, ICIs combined with chemotherapy are the standard of care for metastatic NSCLC without actionable mutations. In tumors with high PD-L1 expression, ICI monotherapy is also an effective option. In some cases, treatment associated toxicities and co-existing morbidities remain a challenge. In the case of patients with autoimmune disorders, they may experience exacerbation of the underlying autoimmune disease following ICI initiation and also an increased risk of immune-related adverse effects (irAE). People with underlying multiple sclerosis (MS) have mostly been excluded from clinical trials of ICIs, so data on their safety in the setting of MS is limited. This report presents three clinical cases from our institution involving patients with NSCLC and pre-existing MS who were treated with ICIs.

Mechanisms of primary resistance to immune checkpoint inhibitors in NSCLC

Immune checkpoint inhibitors (ICIs) redefined the therapeutics of non-small cell lung cancer (NSCLC), leading to significant survival benefits and unprecedented durable responses. However, the majority of the patients develop resistance to ICIs, either primary or acquired. Establishing a definition of primary resistance to ICIs in different clinical scenarios is challenging and remains a work in progress due to the changing landscape of ICI-based regimens, mainly in the setting of early-stage NSCLC. The mechanisms of primary resistance to ICIs in patients with NSCLC include a plethora of pathways involving a cross-talk of the tumor cells, the tumor microenvironment and the host, leading to the development of an immunosuppressive phenotype. The optimal management of patients with NSCLC following primary resistance to ICIs represents a significant challenge in current thoracic oncology. Research in this field includes exploring other immunotherapeutic approaches, such as cancer vaccines, and investigating novel antibody-drug conjugates in patients with NSCLC.

Immunotherapy in advanced non-small cell lung cancer: What to do for the 'Invisible' patients after IPSOS trial results?

BACKGROUND

Immune checkpoint inhibitors (ICIs) are currently included in the standard of care of the first-line treatment of advanced/metastatic non-small cell lung cancer (NSCLC). However, a relevant group of clinically unfit patients, including poor Performance Status, Elderly, and those with relevant comorbidities, are not represented in most pivotal clinical trials.

METHODS

An expert panel meeting commentary was virtually held to point out the key issues in treating such 'invisible' patients and to review the available evidence.

RESULTS

Overall, clinically unfit patients represent up to 50% of patients with diagnosis of advanced/metastatic NSCLC. Few dedicated studies with immunotherapy were conducted in this population. Among them, the IPSOS trial finally answers the issue of first line immunotherapy in platinum-unfit patients with advanced NSCLC, demonstrating atezolizumab improved OS and good tolerability compared to monochemotherapy.

CONCLUSIONS

Atezolizumab monotherapy can be considered a valid first-line treatment in patients with advanced NSCLC who are unfit to receive platinum-based chemotherapy, including elderly, those with poor PS and/or comorbidities.

Prognostic and predictive biomarkers with therapeutic targets in nonsmall-cell lung cancer: A 2023 update on current development, evidence, and recommendation

BackgroundSince the publication of the original work in 2014, significant progress has been made in the characterization of genomic alterations that drive oncogenic addiction of nonsmall cell lung cancer (NSCLC) and how the immune system can leverage non-oncogenic pathways to modulate therapeutic outcomes. This update evaluates and validates the recent and emerging data for prognostic and predictive biomarkers with therapeutic targets in NSCLC.Data sourcesWe performed a literature search from January 2015 to October 2023 using the keywords non-small cell lung cancer, clinical practice guidelines, gene mutations, genomic assay, immune cancer therapy, circulating tumor DNA, predictive and prognostic biomarkers, and targeted therapies.Study selection and data extractionWe identified, reviewed, and evaluated relevant clinical trials, meta-analyses, seminal articles, and published clinical practice guidelines in the English language.Data synthesisRegulatory-approved targeted therapies include those somatic gene alterations of EGFR ("classic" mutations, exon 20 insertion, and rare EGFR mutations), ALK, ROS1, BRAF V600, RET, MET, NTRK, HER2, and KRAS G12C. Data for immunotherapy and circulating tumor DNA in next-generation sequencing are considered emerging, whereas the predictive role for PIK3CA gene mutation is insufficient.ConclusionsAdvances in sequencing and other genomic technologies have led to identifying novel oncogenic drivers, novel resistance mechanisms, and co-occurring mutations that characterize NSCLC, creating further therapeutic opportunities. The benefits associated with immunotherapy in the perioperative setting hold initial promise, with their long-term results awaiting.

Navigating chemotherapy and immunotherapy in early-stage lung cancer. A critical review and statements from INTERACTION group

INTRODUCTION

During the recent INTERACTION group congress held on February 16-17, 2024, in Milan, Italy, many aspects of early-stage lung cancer treatment were explored. This review delves into perioperative treatment, a rapidly evolving field with an expanding therapeutic arsenal that includes chemotherapy, target therapy, and immunotherapy. The challenge remains in tailoring treatment strategies to individual patients, identifying patients best suited for surgery versus those necessitating trimodal treatment, particularly in distinguishing surgical candidates from those requiring multimodal approaches and not suitable for surgical approach.

MATERIALS AND METHODS

We conducted a literature review of phase III trials on immunotherapy and target therapy in early-stage non-small cell lung cancer (NSCLC), searching in MEDLINE, EMBASE and LILACS, adding the latest data from the European Society of Medical Oncology (ESMO) 2023 and 2024, American Society of Clinical Oncology (ASCO) 2024, and the World Conference on Lung Cancer (WCLC) 2024 conferences. A guidance on unresolved and controversial issues from the panel has been reported, also highlighting the remaining limitations that warrant further investigation and refinement in this field.

RESULTS

Most recent data on early-stage NSCLC have been critically reviewed. The panel emphasized the importance of distinguishing, from the outset in a multidisciplinary setting, patients who are suitable for surgical treatment from those who are not. In this context, the importance of accurate staging at the time of diagnosis was highlighted. A paradigm shifts regarding the timing of molecular NGS DNA and RNA testing is strongly recommended.

CONCLUSION

Decisions regarding perioperative treatment in early-stage lung cancer demand early consideration, involving a multidisciplinary team and require an upfront NGS analysis. Such an approach ensures personalized care aligned with each patient's unique characteristics, optimizing treatment efficacy and overall well-being.

Real-World Evaluation of Immune-Related Endocrinopathies in Metastatic NSCLC Patients Treated with ICIs in Romania

(1) Background: Exploring real-world data (RWD) regarding immune-related adverse events (irAEs) is crucial to better understand the efficacy and safety of immunotherapy in cancer patient populations excluded from clinical trials. An analysis was conducted to evaluate the presumptive predictive causality between endocrine irAEs and the efficacy of immune check-point inhibitors (ICIs) in metastatic non-small-cell lung cancer (mNSCLC) patients treated in daily practice in Romania. (2) Methods: This was a retrospective cohort study of mNSCLC patients treated with ICIs in a tertiary level hospital in Romania for a period of almost seven years, from November 2017 till July 2024. Endocrine irAEs were well defined as any occurring autoimmune endocrinopathy during ICIs and related to immunotherapy. The hospital endocrinologist (M.C.C.O) diagnosed, treated, and followed these endocrine irAEs in a multidisciplinary approach. We investigated multiple medical variables to assess their impact on ICI effectiveness. Descriptive and statistical analyses were performed. (3) Results: Of 487 cancer patients treated with ICIs, we identified 215 mNSCLC patients who were evaluated for endocrine irAEs and co-medications during ICI therapy. Forty-seven (21.8%) patients experienced endocrine irAEs, thyroiditis being the most frequent and prevalent autoimmune endocrinopathy in 60% of cases. Endocrine irAEs were statistically significant, correlated with ICI efficacy (p = 0.002) for survival analysis. Steroids and proton-pump inhibitors used as co-medication during ICIs had a negative impact on response to therapy. (4) Conclusions: Endocrine irAEs might be considered predictive biomarkers for successful immunotherapy in mNSCLC patients. Co-medication during ICIs had a major influence on the effectiveness of these cutting-edge therapies. RWD plays an important role for oncology daily practice whenever clinical trial evidence is not available to guide decision.

The Toxicity Profile of Pemetrexed in Non-Small Cell Lung Cancer Patients With Moderate Renal Impairment: A Retrospective Cohort Study

PURPOSE

Pemetrexed is a key drug in the immunochemotherapy of non-small cell lung cancer (NSCLC). However, its use is contraindicated in patients with renal impairment due to severe toxicity risks. As renal impairment is common in lung cancer patients, healthcare professionals face a dilemma between withholding effective treatment and risking toxicity. Real-world data on pemetrexed toxicity may aid in this decision. The primary objective of this study was to describe the toxicity profile of pemetrexed treatment in NSCLC patients with renal impairment.

PATIENTS AND METHODS

This multicenter, descriptive, retrospective study was conducted across 9 hospitals in the Netherlands between 2015 and 2024. Patients included had a diagnosis of NSCLC, received ≥ 1 cycle of standard dose pemetrexed, and had a baseline creatinine clearance (CrCL)<45 mL/min. Data were collected on patient and treatment characteristics, hematological and nonhematological toxicity incidences, treatment discontinuation, dose reduction, and treatment-related hospitalization.

RESULTS

Forty-four patients were included, with median CrCL 41.1 mL/min (interquartile range: 35.0-43.9). Thirty-one patients (70%) did not finish 4 cycles of pemetrexed treatment, with 14 patients (45%) discontinuing due to pemetrexed-associated toxicity. More than half of patients (n = 28; 64%) were hospitalized due to treatment-related toxicity. Seventeen patients (39%) developed grade 3-4 neutropenia and leukopenia. Gastro-intestinal toxicity grade 3 to 4 occurred in fifteen (34%) patients.

CONCLUSION

Pemetrexed treatment of NSCLC patients with moderate renal impairment was associated with high incidence of hematological toxicity, hospitalization, dose reduction, and treatment discontinuation. These results highlight the necessity of developing new treatment regimens to enable safe pemetrexed-based immunochemotherapy in NSCLC patients with renal impairment.

Comparative efficacy of immunotherapy-based treatment versus chemotherapy-only in patients with unresectable NSCLC with disease progression post chemoradiation and durvalumab

INTRODUCTION

The current standard of care for fit patients with unresectable stage III NSCLC involves concurrent chemoradiation (CRT) followed by durvalumab. Disease recurrence occurs in approximately 2/3 of patients, often necessitating subsequent systemic therapy. The only available data about re-challenge immune checkpoint blockers (ICB) in this setting derives from small retrospective series. We evaluated progression free survival (PFS) and overall survival (OS) in patients receiving either ICB-based therapy versus a chemotherapy (CT)-only for disease progression after CRT and durvalumab.

MATERIALS AND METHODS

Multicenter retrospective study, conducted across 10 centers in Italy, the USA, Israel, and The Netherlands. Consecutive patients with relapsed NSCLC following CRT and durvalumab were enrolled.

RESULTS

A total of 197 patients met the eligibility criteria: 93 received CT ( ± anti-VEGF), and 104 received an ICB-based treatment ( ± CT). The median PFS for patients receiving an ICB-based versus a CT-only regimen was 5.9 (95 % CI 4.3-7.6) versus 4.9 months (95 % CI 3.9-5.8), respectively (p = 0.011, HR: 0.67, 95 % CI 0.49-0.91). The median OS was 14.6 months (95 % CI 9.9-19.4) versus 8.9 (95 % CI 7.4-10.4), respectively (p = 0.005, HR: 0.61, 95 % CI 0.43-0.86). Patients with PFS ≥ 12 months on durvalumab, treated with subsequent ICB or CT median OS was 22.0 (95 % CI: 12.9-31.2) 9.8 months (95 % CI: 4.3-15.2) respectively (p = 0.024). Among patients with a PFS < 12 months on durvalumab there was no significant OS difference between ICB and CT arms.

CONCLUSIONS

ICB retreatment at disease progression after CRT and durvalumab might offer an OS benefit over CT in patients who do not relapse during durvalumab treatment.

Diagnostic accuracy in NSCLC lymph node staging with Total-Body and conventional PET/CT

INTRODUCTION

Our aim was to characterize the diagnostic accuracy indices for nodal (N)-staging with [18F]FDG Total-Body (TB) and short-axial field-of-view (SAFOV) PET/CT in non-small cell lung cancer (NSCLC) patients referred for staging or restaging.

METHODS

In this prospective single center cross-over head-to-head comparative study 48 patients underwent [18F]FDG TB and SAFOV PET/CT on the same day. In total 700 lymph node levels (1R/L, 2R/L, 3a/p, 4R/L, 5, 6, 7, 8R/L, 9R/L, 10-14R/L) of 28 patients could be correlated to a composite reference standard (histopathological correlation, imaging after localized or systemic treatment), which allowed determination of true positive (TP), false positive (FP), true negative (TN) and false negative (FN) lesions. Lymph nodes were characterized semi-quantitatively by maximum standardized uptake value (SUVmax), tumor-to-background ratio (TBR), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) leading to threshold for each scanner.

RESULTS

TB and SAFOV PET/CT showed high diagnostic accuracy indices for patient-based N-staging. Sensitivity and specificity were 86.0% (CI: 77.0-95.0%) and 98.3% (CI: 97.3-99.3%) for TB; 77.2% (CI: 66.3-88.1%) and 97.4% (CI: 96.1-98.6%) for SAFOV PET. Positive predictive value was higher for TB (81.7%, CI: 71.9-91.5%) compared to SAFOV PET (72.1%, CI: 60.9-83.4%). However, this finding was not statistically significant (p = 0.08). Negative predictive values for TB (98.6%, CI: 97.9-99.6%) and SAFOV PET/CT (98.0%, CI: 96.9-99.1%) were comparable. Overall, NSCLC N-staging was affected in six cases on SAFOV and only in one case on TB PET/CT. Semi-quantitative analysis revealed a threshold of SUVmax 3.0 to detect TP lesions on both scanners. However, TBR, MTV and TLG thresholds were lower on TB compared to SAFOV PET (TBR: 1.2 vs. 1.7, MTV: 0.5 ml vs. 1.0 ml and TLG: 1.0 ml vs. 3.0 ml).

CONCLUSION

TB and SAFOV PET/CT showed high diagnostic accuracy indices for N-staging in NSCLC patients. Sensitivity and PPV on TB PET/CT were slightly higher, compared to SAFOV PET/CT without statistical significance. However, TB PET/CT showed lower rate of incorrect N-staging and lower semi-quantitative thresholds for the detection positive mediastinal lymph nodes. Therefore, TB PET/CT might be advantageous in detecting small and low [18F]FDG-avidity mediastinal lymph node metastases in NSCLC patients.

Clinical Characteristics and Management of Ocular Metastases

Intraocular metastases represent the most common type of intraocular tumors in adults. In most cases, the metastases originate from primary breast and lung cancers. Effective management of patients with intraocular metastatic disease requires a multidisciplinary approach involving ophthalmologists, oncologists, and radiation therapists. The primary goals of treatment are disease control, maintenance of optimal quality of life, and preservation of functional vision. This article provides an in-depth overview of intraocular metastases, with special emphasis on the practical aspects of their diagnosis and treatment based on the most recent literature.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Targeting Immune Checkpoint Inhibitors for Non-Small-Cell Lung Cancer: Beyond PD-1/PD-L1 Monoclonal Antibodies

Non-small-cell lung cancer (NSCLC) remains a leading cause of cancer-related mortality worldwide. Immunotherapy targeting the PD-1/PD-L1 axis has revolutionized treatment, providing durable responses in a subset of patients. However, with fewer than 50% of patients achieving significant benefits, there is a critical need to expand therapeutic strategies. This review explores emerging targets in immune checkpoint inhibition beyond PD-1/PD-L1, including CTLA-4, TIGIT, LAG-3, TIM-3, NKG2A, and CD39/CD73. We highlight the biological basis of CD8 T cell exhaustion in shaping the antitumor immune response. Novel therapeutic approaches targeting additional inhibitory receptors (IR) are discussed, with a focus on their distinct mechanisms of action and combinatory potential with existing therapies. Despite significant advancements, challenges remain in overcoming resistance mechanisms and optimizing patient selection. This review underscores the importance of dual checkpoint blockade and innovative bispecific antibody engineering to maximize therapeutic outcomes for NSCLC patients.

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

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

Diverse clinical outcomes for the EGFR‑mutated and ALK‑rearranged advanced non‑squamous non‑small cell lung cancer

EGFR and ALK are key driver mutations in non-small cell lung cancer (NSCLC). Tyrosine kinase inhibitors are recommended as the first-line treatment for advanced NSCLC with driving oncogenes because they have fewer side effects and provide better disease control than chemotherapy. The present retrospective analysis aimed to investigate how altered driver genes impact cancer outcomes and clinical presentation. A total of 628 patients with advanced-stage NSCLC and documented EGFR and ALK mutations were enrolled at Changhua Christian Hospital in Taiwan between August 2011 and January 2021. EGFR mutations were identified by PCR. ALK rearrangements were identified by immunostaining. Patients without EGFR or ALK mutations were labeled as wild-type (WT). EGFR mutation was detected in 446 (71.02%) patients, ALK rearrangement in 36 (5.73%) patients and WT in 146 (23.25%) patients. EGFR mutations resulted in higher frequency of lung, brain and multiple extrapulmonary metastases than ALK rearrangement. The ALK group exhibited the longest median overall survival (OS), followed by EGFR and WT groups (ALK: 51.60±13.32, EGFR: 24.03±1.22 and WT: 19.63±2.43 months, respectively; P=0.011). In patients with brain metastases, ALK group had a longer median OS than the EGFR group. Because there were few recruited patients with ALK rearrangement, the results were not significant. According to the results of Cox regression model analysis, driver mutations with EGFR and ALK, lower smoking pack-years, younger age, better performance status, no pleural metastasis and fewer extrapulmonary metastases were key prognostic factors. In conclusion, diverse clinical outcomes are driven by different driver mutations. EGFR mutation leads to more extrapulmonary metastases. Median OS was superior in ALK-rearranged NSCLC than EGFR-mutated NSCLC regardless of brain metastases.

Artificial intelligence-based biomarkers for treatment decisions in oncology

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

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

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

Intratumoral Collagen Deposition Supports Angiogenesis Suggesting Anti-angiogenic Therapy in Armored and Cold Tumors

A previous study classifies solid tumors based on collagen deposition and immune infiltration abundance, identifying a refractory subtype termed armored & cold tumors, characterized by elevated collagen deposition and diminished immune infiltration. Beyond its impact on immune infiltration, collagen deposition also influences tumor angiogenesis. This study systematically analyzes the association between immuno-collagenic subtypes and angiogenesis across diverse cancer types. As a result, armored & cold tumors exhibit the highest angiogenic activity in lung adenocarcinoma (LUAD). Single-cell and spatial transcriptomics reveal close interactions and spatial co-localization of fibroblasts and endothelial cells. In vitro experiments demonstrate that collagen stimulates tumor cells to express vascular endothelial growth factor A (VEGFA) and directly enhances vessel formation and endothelial cell proliferation through sex determining region Y box 18 (SOX18) upregulation. Collagen inhibition via multiple approaches effectively suppresses tumor angiogenesis in vivo. In addition, armored & cold tumors display superior responsiveness to anti-angiogenic therapy in advanced LUAD cohorts. Post-immunotherapy resistance, the transformation into armored & cold tumors emerges as a potential biomarker for selecting anti-angiogenic therapy. In summary, collagen deposition is shown to drive angiogenesis across various cancers, providing a novel and actionable framework to refine therapeutic strategies combining chemotherapy with anti-angiogenic treatments.

Immunotherapy for advanced-stage squamous cell lung cancer: the state of the art and outstanding questions

Immune-checkpoint inhibitors (ICIs) have transformed the treatment paradigm for advanced-stage squamous non-small-cell lung cancer (LUSC), a histological subtype associated with inferior outcomes compared with lung adenocarcinoma. However, only a subset of patients derive durable clinical benefit. In the first-line setting, multiple ICI regimens are available, including anti-PD-(L)1 antibodies as monotherapy, in combination with chemotherapy, or with an anti-CTLA4 antibody with or without chemotherapy. Several important questions persist regarding the optimal regimen for individual patients, particularly how to identify patients who might benefit from adding chemotherapy and/or anti-CTLA4 antibodies to anti-PD-(L)1 antibodies. An urgent need exists for predictive biomarkers beyond PD-L1 to better guide precision oncology approaches. Deeper knowledge of the underlying molecular biology of LUSC and its implications for response to ICIs will be important in this regard. Integration of this knowledge into multi-omics methods coupled with artificial intelligence might enable the development of more robust biomarkers. Finally, several novel therapeutic strategies, including novel ICIs, bispecific antibodies and personalized cancer vaccines, are emerging. Addressing these unresolved questions through innovative clinical trials and translational research will be crucial to further improving the outcomes of patients with LUSC. In this Review, we provide a comprehensive overview of current immunotherapeutic approaches, unresolved challenges and emerging strategies for patients with LUSC.

[Treatment with peri-operative immunotherapy of resectable PCNBs]

For decades, early-stage, resecable, although potentially curable, non-small cell lung cancer (NSCLC) has been marred by unacceptably high recurrence rates. Anti-PD(L)1 immune checkpoint inhibitors have revolutionized the treatment of advanced NSCLC; the recent approvals of these drugs in the perioperative setting will now transform the paradigm therapeutics of localized NSCLC. In this review, we focus on the role of perioperatively administered immune checkpoint inhibitors in resectable NSCLC, synthesizing the results of early clinical trials, and discussing future directions.

Primary and Acquired Resistance to Immunotherapy with Checkpoint Inhibitors in NSCLC: From Bedside to Bench and Back

Immunotherapy with checkpoint inhibitors has become the cornerstone of systemic treatment for non-oncogene addicted non-small-cell lung cancer. Despite its pivotal role, a significant proportion of patients-approximately 70-85%-either exhibit primary resistance to PD-1 blockade or develop acquired resistance following an initial benefit, even in combination with chemotherapy and/or anti-CTLA-4 agents. The phenomenon of primary and acquired resistance to immunotherapy represents a critical clinical challenge, largely based on our incomplete understanding of the mechanisms of action of immunotherapy, and the resulting lack of accurate predictive biomarkers. Here, we review the definitions and explore the proposed mechanisms of primary and acquired resistance, including those related to the tumor microenvironment, systemic factors, and intrinsic tumor characteristics. We also discuss translational data on adaptive changes within tumor cells and the immune infiltrate following exposure to checkpoint inhibitors. Lastly, we offer a comprehensive overview of current and emerging therapeutic strategies designed to prevent primary resistance and counteract acquired resistance.

Impact of Immune Checkpoint Inhibitors and Local Radical Treatment on Survival Outcomes in Synchronous Oligometastatic NSCLC

Introduction

The impact of an immune checkpoint inhibitor (ICI)-based systemic treatment strategy with or without local radical treatment (LRT) on outcomes for patients with NSCLC and synchronous oligometastatic disease (sOMD) is unknown.

Methods

Multicenter retrospective study including adequately staged patients, with sOMD NSCLC (maximum five metastases in three organs [European Organization for Research and Treatment of Cancer definition]) between January 1, 2015 and December 31, 2022, treated with a first-line ICI-based versus chemotherapy-only regimen. Primary end points were progression-free survival and overall survival (OS) for an ICI-based versus chemotherapy-only strategy. Subgroup analyses were performed for patients who were deemed candidates for LRT in the multidisciplinary meeting and those proceeding to LRT.

Results

A total of 416 patients were included, treated with chemotherapy-ICI (n = 138) or chemotherapy-only (n = 278), 319 out of 416 were deemed candidates by multidisciplinary meetings for LRT, whereas 192 (60%) proceeded to LRT. The median OS was significantly longer in the chemotherapy-ICI compared with the chemotherapy-only group (33.6 versus 15.9 mo, hazard ratio [HR] = 0.5, 95% confidence interval [CI]: 0.4-0.7, p < 0.001), in the subgroups who were candidate for LRT (36.1 versus 17.2 mo, HR = 0.5, 95% CI: 0.4-0.7, p < 0.001) and those proceeding to LRT (not reached versus 23.1 mo, HR = 0.4, 95% CI: 0.2-0.7, p < 0.001). In multivariate analysis, an ICI-based strategy was associated with improved survival in the total group (HR = 0.6, 95% CI: 0.4-0.9, p < 0.001), in those with intention of LRT (HR = 0.6, 95% CI: 0.4-0.9, p = 0.02) and those who proceeded to LRT (HR = 0.3, 95% CI: 0.1-0.6, p = 0.002).

Conclusions

An ICI-based systemic treatment strategy (±LRT) is associated with improved survival compared with chemotherapy-only (±LRT) for patients with sOMD NSCLC. Prospective randomized trial data are necessary to identify patients most likely to benefit from adding LRT.