Atezolizumab for First-Line Treatment of Metastatic Nonsquamous NSCLC

Clinical impact of cancer cachexia on the outcome of patients with non-small cell lung cancer with PD-L1 tumor proportion scores of ≥50% receiving pembrolizumab monotherapy versus immune checkpoint inhibitor with chemotherapy

This retrospective, multicenter cohort study aimed to determine whether cancer cachexia serves as a biomarker for determining the most effective treatment for patients having non-small-cell lung cancer (NSCLC) with high programmed death ligand 1 (PD-L1) expression treated with immune checkpoint inhibitors (ICIs) alone or combined with chemotherapy (ICI/chemotherapy). We included 411 patients with advanced NSCLC with a PD-L1 tumor proportion score of ≥50%. The patients were treated with pembrolizumab monotherapy or ICI/chemotherapy. Cancer cachexia was defined as a weight loss of >5% of the total body weight or a body mass index of <20 kg/m2 coupled with an additional weight loss of >2% within 6 months before starting treatment. Eighty-five (21%) patients met the cancer cachexia criteria. Overall survival (OS) was significantly shorter in patients with cachexia than in those without cachexia in both the pembrolizumab monotherapy group (17.2 vs. 35.8 months, p < 0.001) and the ICI/chemotherapy group (27.0 months vs. not reached, p = 0.044). However, after stratifying by cancer cachexia status, no significant difference in OS was observed between the pembrolizumab monotherapy and chemoimmunotherapy groups, regardless of cachexia. In conclusion, ICI/chemotherapy offers limited benefits for NSCLC patients with high PD-L1 expression and concurrent cancer cachexia. Considering the frailty associated with cachexia, ICI monotherapy may be preferred to ICI/chemotherapy for these patients. New interventions that can better address the negative prognostic impact of cachexia in patients treated using ICIs with or without chemotherapy remain warranted.

The role of cisplatin in modulating the tumor immune microenvironment and its combination therapy strategies: a new approach to enhance anti-tumor efficacy

Cisplatin is a platinum-based drug that is frequently used to treat multiple tumors. The anti-tumor effect of cisplatin is closely related to the tumor immune microenvironment (TIME), which includes several immune cell types, such as the tumor-associated macrophages (TAMs), cytotoxic T-lymphocytes (CTLs), dendritic cells (DCs), myeloid-derived suppressor cells (MDSCs), regulatory T cells (Tregs), and natural killer (NK) cells. The interaction between these immune cells can promote tumor survival and chemoresistance, and decrease the efficacy of cisplatin monotherapy. Therefore, various combination treatment strategies have been devised to enhance patient responsiveness to cisplatin therapy. Cisplatin can augment anti-tumor immune responses in combination with immune checkpoint blockers (such as PD-1/PD-L1 or CTLA4 inhibitors), lipid metabolism disruptors (like FASN inhibitors and SCD inhibitors) and nanoparticles (NPs), resulting in better outcomes. Exploring the interaction between cisplatin and the TIME will help identify potential therapeutic targets for improving the treatment outcomes in cancer patients.

Identification of small molecule activators targeting TYK2 pseudokinase domain

Tyrosine kinase 2 (TYK2) plays a crucial role in both adaptive and innate immune responses. The catalytic activity of the TYK2 JH1 kinase domain is controlled by the TYK2 JH2 pseudokinase domain and stabilized to maintain its inactive state until the upstream receptor activations. Here, we report the discovery of aminopyridine analogs as novel TYK2 activators through structural modification of a known JH2 binder. Compound 16b demonstrated a dose-dependent increase in TYK2 enzymatic activity.

A novel anti-PD-L1 DNA aptamer, Apta35 enhances non-small cell lung cancer cell cytotoxicity and apoptosis through lung cancer-activated T lymphocytes

The prevalence of Programmed death ligand 1 (PD-L1) expression in the population of NSCLC patients and blocking the PD1/PD-L1 pathway by inhibiting the PD-1 receptor on immune cells or the PD-L1 ligand on tumour and/or immune cells can inhibit tumour growth. EFBALite algorithm that enables efficient and cost-effective selection of aptamers, expediting the process. Here, we present the development, computational validation, and in vitro analysis of NSCLC of DNA aptamers targeting PD-L1. The Gibbs free energy of two anti-PD-L1 aptamers, Apta35 and Apta90 with -3.06 and - 2.4 kcal/mol respectively. The docking score for Apta35 was -272.3 and 1171.765 for HDOCK and ZDOCK respectively. Further, the Apta35 was taken for the in vitro studies as it was more stable and incubated with NCI-H460. Initially, we confirmed the binding of the TAMRA-labelled Apta35 to the NCI-H460 cell surface through microscopic imaging and further confirmed through FACS analysis. Further experimental results showed that the Apta35 treated along with the act-T cells group reduced the percentage of viability (28 ± 3.5), increased toxicity, and reduced count of NCI-H460 cells when compared with the cells treated only with the act-T cells concerning the treatment to 50 nM concentration. In summary, targeting PD-L1 with a specific aptamer provides an innovative strategy for targeting NSCLC. Apta35 aptamer showed no significant toxicity in the BALB/c nude mice while it was injected every 2 days for a total of 12 days of treatment.

Regimen Selection for Chemoimmunotherapy in Nonsquamous Non-Small Cell Lung Cancer with Low PD-L1 Expression: A Multicenter Retrospective Cohort Study

BACKGROUND

Although chemoimmunotherapy is recommended for advanced nonsquamous non-small cell lung cancer (NSCLC) with low programmed cell death ligand 1 (PD-L1) expression, no head-to-head comparisons of immune checkpoint inhibitors (ICIs) have been performed. Therefore, we compared the effect and safety of regimens in these patients to guide evidence-based treatment.

METHODS

This retrospective study included patients with advanced nonsquamous NSCLC with a PD-L1 tumor proportion score of 1% to 49% administered ICI combination platinum-based chemotherapy between May 2018 and May 2023 at 19 institutions in Japan. The main analysis compared survival outcomes and the incidence of grade ≥3 adverse events among regimens.

RESULTS

Among 316 included patients (median [range] age, 69 [36-89] years; 242 males; 41 never smokers), 200 (63%), 68 (22%), and 48 (15%) received chemotherapy combined with anti-programmed cell death protein 1 (PD-1), anti-PD-L1, and anti-PD-1/cytotoxic T-lymphocyte associated protein 4 (CTLA-4) antibodies, respectively. The median overall survival times were 28.6, 23.1, and 24.4 months (P = .41), and the median progression-free survival times were 9.4, 7.2, and 8.7 months (P = .28) in the anti-PD-1/Chemo, anti-PD-L1/Chemo and anti-PD-1/CTLA-4/Chemo groups, respectively. The anti-PD-1/CTLA-4/Chemo group had the lowest incidence of hematologic toxicity (P = .13) and the highest incidence of nonhematologic toxicity (P = .07). The incidence of grade ≥3 pneumonitis was significantly lower in the anti-PD-L1/Chemo group (P = .049).

CONCLUSIONS

Despite comparable survival benefits, adverse events differed among three regimens in patients with low PD-L1 expression. Notably, anti-PD-L1 antibody combination chemotherapy may reduce the risk of severe pneumonitis.

Hypoxia-inducible factor-targeting therapy augmented the sensitivity to programmed death ligand-1 blockade by enhancing interferon-γ-induced chemokines in tumor cells

Immune checkpoint inhibitors (ICIs) targeting programmed death ligand-1 (PD-L1) provide clinical benefits for various advanced malignancies. However, the predictive factors that determine sensitivity to ICIs have not been fully elucidated. We focused on tumor-derived CXCL10/11 as a pivotal factor that determines the response to PD-L1 blockade by regulating T cell accumulation and tumor angiogenesis. We previously reported that CXCL10/11 was upregulated by interferon (IFN)-γ in ICI-sensitive tumor cells but not in ICI-resistant cells, including mouse Lewis lung carcinoma (LLC). In the present study, gene silencing of tumor-derived CXCL10/11 induced resistance to PD-L1 blockade in AB1-HA mesothelioma cell-bearing mice. To identify the mechanisms underlying ICI resistance, we performed a microarray analysis to compare the IFN-γ-inducible genes between ICI-sensitive AB1-HA and ICI-resistant LLC in vitro. A pathway analysis based on microarray data indicated that hypoxia-inducible factor (HIF) 1A is the key signal that inhibits CXCL10/11 expression. We revealed that the HIF1A inhibitors echinomycin (EC) and YC-1 upregulated CXCL10/11 genes induced by IFN-γ in tumor cells in vitro. In addition, combination therapy with PD-L1 blockade and EC demonstrated synergistic antitumor effects in LLC-bearing mice. Combination therapy enhanced tumor infiltration of CD8 T cells and suppressed tumor angiogenesis. The present study suggests that HIF1A signaling in tumor cells dominates ICI resistance via the downregulation of tumor-derived CXCL10/11.

Decoding tumor angiogenesis: pathways, mechanisms, and future directions in anti-cancer strategies

Angiogenesis, a crucial process in tumor growth and metastasis, necessitates targeted therapeutic intervention. This review reviews the latest knowledge of anti-angiogenesis targets in tumors, with emphasis on the molecular mechanisms and signaling pathways that regulate this process. We emphasize the tumor microenvironment's role in angiogenesis, examine endothelial cell metabolic changes, and evaluated potential therapeutic strategies targeting the tumor vascular system. At the same time, we analyzed the signaling pathway and molecular mechanism of tumor angiogenesis in detail. In addition, this paper also looks at the development trend of tumor anti-angiogenesis drugs, including their future development direction and challenges, aiming to provide prospective insight into the development of this field. Despite their potential, anti-angiogenic therapies encounter challenges like drug resistance and side effects, necessitating ongoing research to enhance cancer treatment strategies and the efficacy of these therapies.

Atezolizumab with carboplatin plus nab-paclitaxel combination therapy for advanced nonsquamous non-small cell lung cancer with impaired renal function: A multicenter, single-arm phase 2 trial (RESTART, LOGiK 2002)

BACKGROUND

The current standard of care for advanced non-small cell lung cancer (NSCLC) without driver oncogenes is platinum-based chemotherapy together with immune checkpoint inhibition. However, most phase 3 trials of such combination therapy have excluded patients with renal impairment, with prospective data on its efficacy and safety in such patients thus being limited.

METHODS

This multicenter, single-arm phase 2 study enrolled chemotherapy-naïve individuals with advanced nonsquamous NSCLC and renal impairment defined as a creatinine clearance (CCr) of 15 to <45 mL/min. Patients received four cycles of atezolizumab in combination with carboplatin plus nab-paclitaxel, followed by atezolizumab alone. The primary endpoint of the study was objective response rate as determined by Response Evaluation Criteria in Solid Tumors.

RESULTS

Twenty-five patients were enrolled from 13 centers. The median age was 78 years (range, 63-83 years). Median CCr was 38.0 mL/min (range, 19.0-44.3 mL/min). There were no treatment-related deaths or cases requiring hemodialysis. Worsening of chronic kidney disease to grade 4, defined as a CCr of <15 mL min-1 1.73 m-2, occurred in two patients (8 %), with the decreases in CCr being transient and both patients subsequently recovering. The objective response rate was 36.0 % (60 % confidence interval, 28.4-44.4 %), and the study did not meet its primary endpoint. Median progression-free survival and overall survival were 7.1 and 19.9 months, respectively.

CONCLUSIONS

Carboplatin plus nab-paclitaxel with atezolizumab is a potentially feasible treatment option for advanced nonsquamous NSCLC with renal impairment.

Efficacy of immunotherapy remained in patients with recurrent/metastatic non-small-cell lung cancer after surgery with or without postoperative thoracic radiotherapy: a bi-center retrospective study

PURPOSE

Since mediastinal lymph node dissection and radiotherapy (RT) have potential unclear impacts on pulmonary lymphatic system, this study aimed to assess the effectiveness of immune checkpoint inhibitors (ICIs) in recurrent/metastatic non-small-cell lung cancer (NSCLC) patients who previously received radical surgery with or without thoracic RT.

METHODS

Clinical data of patients who underwent pulmonary lobectomy with systematic lymphadenectomy (2000.1.1-2021.7.2) and received immunotherapy after progression were retrospectively analyzed. Efficacy was mainly evaluated based on progression-free survival (PFS) from the start of the ICIs. Toxicity was defined as treatment discontinuation due to immune-related adverse effects (irAEs).

RESULTS

Ninety-five patients were enrolled in the final cohort and 30 (31.6%) patients received thoracic RT before ICI treatment. ICIs were administered as a first-line systematic treatment in 52.6% of patients. The median follow-up time was 14.7 months (95% confidence interval [CI] 13.3-18.7 months). The median PFS was 12.3 months (95% CI 8.5-36.6 months). Six (6.3%) patients had treatment suspended due to irAEs. Patients who received RT had comparable median PFS with the non-RT group (17.0 months vs. 11.1 months, p = 0.16). Similar toxicity rates were observed. Similar mPFS were reported in the stage III subgroup (RT vs. non-RT, 8.10 vs. 8.45 months, p = 0.86) or the subgroup treated by ICIs as primary systematic therapy (RT vs. non-RT, 13.6 vs. 16.1 months, p = 0.45).

CONCLUSIONS

ICIs remained effective in recurrent/metastatic NSCLC patients with radical surgery and RT did not significantly compromise therapeutic effects.

Angiogenesis causes and vasculogenic mimicry formation in the context of cancer stem cells

Tumor occurrence, development, invasion, and metastasis are regulated by multiple mechanisms. Among these, angiogenesis promotes tumor progression mainly by supplying tumor tissue and providing channels for tumor metastasis. Cancer stem cells (CSCs) are another important factor affecting tumor progression by involving in tumor initiation and development, while remaining insensitive to conventional antitumor treatments. Among treatment strategies for them, owing to the existence of alternative angiogenic pathways or the risk of damaging normal stem cells, the clinical effect is not ideal. Angiogenesis and CSCs may influence each other in this process. Tumor angiogenesis can support CSC self-renewal by providing a suitable microenvironment, whereas CSCs can regulate tumor neovascularization and mediate drug resistance to anti-angiogenic therapy. This review summarized the role of vascular niche formed by angiogenesis in CSC self-renewal and stemness maintenance, and the function of CSCs in endothelial progenitor cell differentiation and pro-angiogenic factor upregulation. We also elucidated the malignant loop between CSCs and angiogenesis promoting tumor progression. Additionally, we summarized and proposed therapeutic targets, including blocking tumor-derived endothelial differentiation, inhibiting pro-angiogenic factor upregulation, and directly targeting endothelial-like cells comprising CSCs. And we analyzed the feasibility of these strategies to identify more effective methods to improve tumor treatment.

Resistance in Lung Cancer Immunotherapy and How to Overcome It: Insights from the Genetics Perspective and Combination Therapies Approach

Lung cancer with the highest number of new cases diagnosed in Europe and in Poland, remains an example of malignancy with a very poor prognosis despite the recent progress in medicine. Different treatment strategies are now available for cancer therapy based on its type, molecular subtype and other factors including overall health, the stage of disease and cancer molecular profile. Immunotherapy is emerging as a potential addition to surgery, chemotherapy, radiotherapy or other targeted therapies, but also considered a mainstay therapy mode. This combination is an area of active investigation in order to enhance efficacy and overcome resistance. Due to the complexity and dynamic of cancer's ecosystem, novel therapeutic targets and strategies need continued research into the cellular and molecular mechanisms within the tumour microenvironment. From the genetic point of view, several signatures ranging from a few mutated genes to hundreds of them have been identified and associated with therapy resistance and metastatic potential. ML techniques and AI can enhance the predictive potential of genetic signatures and model the prognosis. Here, we present the overview of already existing treatment approaches, the current findings of key aspects of immunotherapy, such as immune checkpoint inhibitors (ICIs), existing molecular biomarkers like PD-L1 expression, tumour mutation burden, immunoscore, and neoantigens, as well as their roles as predictive markers for treatment response and resistance.

Exosomal PD-L1 in non-small cell lung Cancer: Implications for immune evasion and resistance to immunotherapy

Exosomes, characterized by their bilayer lipid structure, are crucial in mediating intercellular signaling and contributing to various physiological processes. Tumor cells produce distinct exosomes facilitating cancer progression, angiogenesis, and metastasis by conveying signaling molecules. A notable feature of these tumor-derived exosomes is the presence of programmed death-ligand 1 (PD-L1) on their surface. The PD-L1/programmed cell death receptor-1 (PD-1) signaling axis serves as a critical immune checkpoint, enabling tumors to evade immune detection and antitumor activity. The advancement of immunotherapy targeting the PD-1/PD-L1 pathway has significantly impacted the treatment landscape for non-small cell lung cancer (NSCLC). Despite its promise, evidence indicates that many patients experience limited responses or develop resistance to PD-1/PD-L1 inhibitors. Recent studies suggest that exosomal PD-L1 contributes to this resistance by modulating immune responses and tumor adaptability. This study reviews the PD-1/PD-L1 pathway's characteristics, current clinical findings on PD-L1 inhibitors in NSCLC, and exosome-specific attributes, with a particular focus on exosomal PD-L1. Furthermore, it examines the growing body of research investigating the role of exosomal PD-L1 in cancer progression and response to immunotherapy, underscoring its potential as a target for overcoming resistance in NSCLC treatment.

Efficacy of atezolizumab, bevacizumab, carboplatin, and paclitaxel for epidermal growth factor receptor mutation-positive advanced non-small cell lung cancer after tyrosine kinase inhibitor failure

BACKGROUND

Non-small cell lung cancer (NSCLC) with driver mutations, notably epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase, shows reduced sensitivity to immune checkpoint inhibitors. A subgroup analysis of the IMpower150 data on patients resistant to EGFR tyrosine kinase inhibitors (EGFR-TKI) before enrollment demonstrated prolonged progression-free survival (PFS) with atezolizumab, bevacizumab, carboplatin, and paclitaxel (ABCP) over bevacizumab, carboplatin, and paclitaxel. However, due to the exploratory nature and small sample size, the efficacy of ABCP post-EGFR-TKI failure is still debated. We evaluated ABCP therapy against other platinum-based regimens without immune checkpoint inhibitors in terms of effectiveness and toxicity.

METHODS

Data from patients with advanced or recurrent NSCLC harboring EGFR-sensitizing mutations treated with platinum-based chemotherapy or ABCP at five Japanese hospitals were retrospectively analyzed. Propensity score matching compared efficacy outcomes, including overall response rate (ORR), PFS, and OS.

RESULTS

Of 183 EGFR mutation carriers, 33 underwent ABCP therapy, while 150 received platinum-based chemotherapy. Following propensity score matching, 32 and 74 patients were analyzed. In the ABCP group, median PFS and OS were 6.8 and 16.7 months compared to 5.8 and 25.7 months with platinum-based chemotherapy, showing no significant differences in PFS (p = 0.46) and OS (p = 0.85). In liver metastases, ABCP yielded a median PFS of 9.9 versus 6.1 months and an ORR of 62.5 % versus 35.7 % relative to platinum-based chemotherapy, without statistical significance (PFS p = 0.16; ORR p = 0.70).

CONCLUSION

Compared with platinum-based chemotherapy, ABCP did not improve effectiveness in patients with EGFR-mutated NSCLC after EGFR-TKI failure.

Ivonescimab in non-small cell lung cancer: harmonizing immunotherapy and anti-angiogenesis

INTRODUCTION

Immunotherapy combined with anti-angiogenesis has become a useful strategy in cancer treatment. Ivonescimab, the first-approved bispecific antibody targeting both immune checkpoint inhibition and anti-angiogenesis, represents a breakthrough over the conventional dual-drug combination approach. The emerging clinical evidence demonstrates promising efficacy and manageable safety profile of ivonescimab in the treatment of non-small cell lung cancer (NSCLC), suggesting its potential role as a cornerstone in the next generation of cancer immunotherapy.

AREAS COVERED

This review presents the pharmacological characteristics of ivonescimab, revisits relevant clinical trials and key data, and provides an in-depth analysis. Additionally, the potential of ivonescimab in NSCLC treatment is discussed, along with its clinical prospects.

EXPERT OPINION

The available clinical data demonstrate that simultaneously targeting both immune checkpoint inhibition and angiogenesis pathways through a single bispecific antibody represents a significant therapeutic advancement in NSCLC treatment. Ivonescimab's innovative dual-targeting mechanism, supported by promising efficacy data from the HARMONi trials and its manageable safety profile, appears to be fundamental to its potential to challenge current standards of care. As the first approved bispecific antibody with this unique mechanism of action, ivonescimab may not only transform current treatment paradigms but also pioneer a new direction in cancer immunotherapy.

Immune Checkpoint Molecules: A Review on Pathways and Immunotherapy Implications

BACKGROUND

Today, treating cancer patients with monoclonal antibodies (mAbs), by targeting immune checkpoints, is one of the most outstanding immunotherapeutic methods. Immune checkpoints are special molecules having regulatory role in immune system responses. Once these molecules are presented on cancer cells, these cells will be capable of evading the immune system through their own specific pathways. This Evasion can be prevented by counterbalancing immune system responses with immune checkpoints related antibodies.

AIMS

The current study aimed to highlight immunotherapy and its methods, describe the immune checkpoints pathways, outline the immune checkpoint inhibitors (ICIs), and recent advances in this field, and sketch an outlook on the best treatment options for the most prevalent cancers.

MATERIALS & METHODS

This research implemented a narrative review method. A comprehensive literature review on the history, molecular and cellular biology, and the clinical aspects of immune checkpoint molecules was performed to illustrate the pathways involved in various cancers. Also, currently-available and future potential immunotherapies targeting these pathways were extracted from the searched studies.

RESULTS

The immune checkpoint family consists of many molecules, including CTLA-4, PD-1, PD-L1, LAG-3, TIM-3, and TIGIT. Attempts to modify these molecules in cancer treatment led to the development of therapeutic monoclonal antibodies. Most of these antibodies have entered clinical studies and some of them have been approved by the Food and Drug Administration (FDA) to be used in cancer patients' treatment plans.

DISCUSSION

With these novel treatments and the combination therapies they offer, there is also hope for better treatment outcomes for the previously untreatable metastatic cancers. In spite of the beneficial aspects of immune checkpoint therapy, similar to other treatments, they may cause side effects in some patients. Therefore, more studies are needed to reduce the probable side effects and uncover their underlying mechanism.

CONCLUSION

Based on the data shown in this review, there is still a lack of knowledge about the complete properties of ICIs and the possible combination therapies that we may be able to implement to achieve a better treatment response in cancer patients.

Chest Tube Drainage, Bone Radiotherapy, and Brain Radiotherapy in Advanced Lung Cancer: A Retrospective Analysis of Associated Factors and Survival

BACKGROUND

Palliative interventions, such as chest tube drainage and radiotherapy for bone and brain metastases, are crucial for managing survival and quality of life in patients with advanced lung cancer.

METHODS

This retrospective study analyzed 8171 patients with unresectable Stage IV lung cancer from the Japanese Joint Committee of Lung Cancer Registry (JJCLCR) database. At treatment initiation, 8.6% of patients underwent chest tube drainage, 9.9% underwent bone radiotherapy, and 11.5% underwent brain radiotherapy. In this study, associated factors for palliative interventions were evaluated, and their impact on patient survival was also assessed.

RESULTS

High-associated factors for upfront chest tube drainage included age ≥ 75 years, ECOG-PS ≥ 2, pleural nodules, and adenocarcinoma, while EGFR mutation, serum albumin ≥ 3.2 mg/dL, adrenal gland, and brain metastases were low-associated factors. For upfront brain radiotherapy, low-associated factors included malignant pleural effusion (MPE) and bone metastases, whereas ECOG-PS ≥ 2 was a high-associated factor. High-associated factors for upfront bone radiotherapy were serum albumin ≥ 3.2 mg/dL, ECOG-PS ≥ 2, adenocarcinoma, and squamous cell carcinoma, while pleural nodules, MPE, liver, and brain metastasis were low-associated factors. Patients receiving upfront bone radiotherapy had shorter survival, whereas survival did not significantly differ for those with or without upfront chest tube drainage or brain radiotherapy.

CONCLUSION

This study identified associated factors for palliative interventions in advanced lung cancer and their association with overall survival. Future prospective studies with more detailed data are necessary to confirm these findings and improve clinical decision-making.

TRIAL REGISTRATION

Approval No. 15,321.

A Real-Word Analysis of the Correlation Between Clinical Efficacy and Predictive Factors of Immune-Related Adverse Events in Patients With Nonsmall Lung Cancer Treated With Nivolumab Plus Ipilimumab

BACKGROUND

The combination of nivolumab and ipilimumab, which act on different immune checkpoint molecules, is a promising first-line treatment strategy for advanced nonsmall cell lung cancer (NSCLC). However, real-world clinical data on this regimen, particularly regarding the relationship between adverse events (AEs) and efficacy, are inadequate.

METHODS

This real-world retrospective study was conducted on patients with advanced or recurrent NSCLC treated using a combination of nivolumab and ipilimumab as a first-line treatment. We extracted the data of consecutive eligible patients from four institutions in Japan between December 2020 and November 2022.

RESULTS

The study population comprised 184 patients who received nivolumab plus ipilimumab (median follow up period: 13.0 months [0.3-35.0]). In total, 81.0% (n = 149) of the patients were men, and the median age was 72.0 years (range: 46-80). The median progression-free survival (PFS) and overall survival (OS) were 6.6 months (95% confidence interval [CI]: 4.7-8.2) and 17.4 months (95% CI: 11.9-20.4), respectively. Skin disorders, liver dysfunction, thyroid dysfunction, and pneumonitis were the most common adverse events (AEs), with AEs occurring in 154 patients (83.7%). The median PFS in the AE group was longer than that in the non-AE group (8.2 vs. 2.6 months, p < 0.0001). The median OS in the AE group was also better than that in the non-AE group (19.3 vs. 6.1 months, p < 0.0001). Multivariate logistic regression analysis identified smoking history and high PD-L1 expression as factors related to the incidence of grade 3 and 4 AEs, respectively. The incidence of multiple AEs revealed a significant association with a longer PFS and OS. Skin disorders, adrenal insufficiency, and eosinophilia were the AEs with the greatest impact on survival.

CONCLUSIONS

Patients who experienced AEs had significantly longer PFS. Among AEs, the occurrence of skin disorders, adrenal insufficiency, and eosinophilia were likely to prolong PFS and OS.

A randomised non-comparative phase II study of atezolizumab, bevacizumab and chemotherapy in EGFR-mutant NSCLC with acquired resistance - The ETOP 15-19 ABC-lung trial

BACKGROUND

ABC-lung explores the potential effect of combining atezolizumab and bevacizumab with either carboplatin/paclitaxel (ABCPac) or pemetrexed (ABPem) in patients with EGFR-mutant NSCLC, resistant to tyrosine kinase inhibitors (TKIs).

METHODS

ABC-lung is a 1:1 randomised, non-comparative, phase II trial, stratified by prior treatment with a third-generation EGFR TKI, evaluating atezolizumab (1200 mg, Q3W) and bevacizumab (15mg/kg, Q3W) with either 4-6 cycles of carboplatin (AUC5, Q3W) and paclitaxel (175-200mg/m2, Q3W) or pemetrexed (500 mg/m2, Q3W) until progression (PD). The study aimed to improve the 1-year progression-free survival (PFS) rate from 18% to 37%, assessed per RECISTv1.1, separately in each arm. To reject the null hypothesis, at least 14 of 45 evaluable patients in each arm needed to be progression-free at 1-year (power 83%, 1-sided a=0.023). Secondary endpoints included overall survival (OS), objective response rate (ORR), PFS, quality of life (QoL) and adverse events (AEs).

RESULTS

Between 09/2020 and 09/2022, 95 patients were randomized (ABCPac:45; ABPem:50) with median follow-up time of 19 months. From the evaluable patients, 9 in ABCPac and 11 in ABPem arms reached 1-year without progression, lower than the success criterion of 14patients. Median PFS was 6.4 months in ABCPac and 7.6 months in the ABPem arms, while median OS was 15.4 months and 15.6 months, respectively. Grade ≥3 treatment-related AEs were experienced by 50% and 42% of patients in ABCPac and ABPem arms, respectively, while no grade 5 AEs were recorded.

CONCLUSIONS

The observed 1-year PFS rate with atezolizumab, bevacizumab in combination with either carboplatin-paclitaxel or pemetrexed was below the aspired rate of 37% in both arms. The safety is consistent with the known toxicity profiles. Clinical trial identification: NCT04245085.

Intratumoral and peritumoral PET/CT-based radiomics for non-invasively and dynamically predicting immunotherapy response in NSCLC

BACKGROUND

We aimed to develop a machine learning model based on intratumoral and peritumoral 18F-FDG PET/CT radiomics to non-invasively and dynamically predict the response to immunotherapy in non-small cell lung cancer (NSCLC).

METHODS

This retrospective study included 296 NSCLC patients, including a training cohort (N = 183), a testing cohort (N = 78), and a TCIA radiogenomic cohort (N = 35). The extreme gradient boosting algorithm was employed to develop the radiomic models.

RESULTS

The COMB-Radscore, which was developed by combining radiomic features from PET, CT, and PET/CT images, had the most satisfactory predictive performance with AUC (ROC) 0.894 and 0.819 in the training and testing cohorts, respectively. Survival analysis has demonstrated that COMB-Radscore is an independent prognostic factor for progression-free survival and overall survival. Moreover, COMB-Radscore demonstrates excellent dynamic predictive performance, with an AUC (ROC) of 0.857, enabling the earlier detection of potential disease progression in patients compared to radiological evaluation solely relying on tumor size. Further radiogenomic analysis showed that the COMB-Radscore was associated with infiltration abundance and functional status of CD8 + T cells.

CONCLUSIONS

The radiomic model holds promise as a precise, personalized, and dynamic decision support tool for the treatment of NSCLC patients.

Randomized phase 2 trial of pembrolizumab alone or in combination with low dose chemotherapy for patients with non-small cell lung cancer and poor performance status

PURPOSE

Immunotherapy alone or in combination with chemotherapy has become the standard of care for medically fit patients who have advanced non-small cell lung cancer (NSCLC) without a driver mutation. The optimal treatment for patients with poor performance status remains an active area of investigation.

PATIENTS AND METHODS

Patients with advanced NSCLC and an Eastern Cooperative Oncology Group performance status (PS) of 2 were randomized to single-agent pembrolizumab at 200 mg every 3 weeks (Arm A) or the same dose of pembrolizumab combined with weekly carboplatin area under the curve 1 and paclitaxel 25 mg/m2 (Arm B). The co-primary outcomes were differences in response rates between the Arms and comparison of each Arm to a historical control. Progression free survival (PFS) and overall survival (OS) were secondary outcomes using intent to treat analyses. Optional blood samples were obtained at baseline and after 2 cycles of treatment, and immune cells were measured using flow cytometry. A subset of post-treatment blood samples were analyzed using single-cell sequencing.

RESULTS

43 patients enrolled with 20 patients evaluable for response in each arm. All enrolled patients were included in survival analyses. Therapy was generally well tolerated with no treatment-related deaths in either arm. Both Arms exceeded the predefined historical control response rate of 10 % (Arm A = 35 %, P = 0.0002; Arm B = 45 %, P < 0.0001). Response rates favored Arm B but the difference was not statistically significant (P = 0.75). Median PFS and OS were not significantly different between the two arms. To compare survival outcomes of either pembrolizumab-based therapy to historical control of platinum-based chemotherapy for patients with PS 2, the two arms were combined. Median PFS was similar to historical control of platinum-based chemotherapy (4.6 months vs 4.6 months historical control). However, overall survival favored pembrolizumab-based therapy at 12 months (44 % vs 31 % historical control, P = 0.062) and 24 months (33 % vs 11 % historical control, P = 0.0001). Twenty patients provided optional blood samples for biomarker analyses. Consistent with prior reports, a numerically longer (but not significant) OS was observed in patients with low regulatory T cells (CD4 + FoxP3 + ) at baseline (14.5 vs 4.6 months, P = 0.068). Abundance of myeloid derived suppressor cells (CD14 + HLA DR-) at baseline did not correlate with clinical outcomes. Single-cell sequencing identified several significant differences in gene expression profiles within the CD14 + cell population for responding and non-responding patients treated with chemoimmunotherapy.

CONCLUSIONS

For patients with poor performance status, adding very low dose chemotherapy to pembrolizumab did not significantly improve clinical outcomes compared to pembrolizumab alone. Patients receiving either of these pembrolizumab-based regimens demonstrated better long-term survival when compared to historical outcomes of platinum-based chemotherapy for the PS 2 population.

Incidence Rates of Cutaneous Immune-Related Adverse Events in Patients with Lung Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

Cutaneous immune-related adverse events (cirAEs) represent a prevalent manifestation of adverse reactions linked to immune checkpoint inhibitors (ICIs) therapy, substantially affecting patients' quality of life. This systematic review and meta-analysis aimed to quantify the pooled incidence of cirAEs in this population and strengthen clinical awareness for early recognition and management.

METHODS

A comprehensive search of PubMed, Embase, CINAHL, Cochrane Library, CBM, CNKI, and Wanfang databases was conducted from inception to December 2022. Literature that reported the incidence of cirAEs in patients with lung cancer receiving ICIs therapy was included. A meta-analysis was conducted using R software, version 4.4.1 to estimate the pooled incidence of cirAEs, and a random-effects model was used for data synthesis. Begg's rank correlation and funnel plots were used to assess publication bias.

RESULTS

A total of 99 articles involving 23,814 patients with lung cancer receiving ICIs therapy were included, with publication dates ranging from 2012 to 2022. The meta-analysis results reveal that the incidence of cirAEs in patients with lung cancer was 20.26% (95% confidence interval [CI (17.12-23.81)]. Significant differences were observed between all subgroups, including continent, study type, combination therapy, dual ICIs therapy, and diagnostic criteria for cirAEs for Grade 1-2 and Grade 3-4 incidences.

CONCLUSIONS

The incidence of cirAEs in patients with lung cancer is relatively high, particularly undergoing combined or dual ICIs therapy. To comprehensively characterize cirAEs in patients with lung cancer, large-scale multicenter studies integrating real-world pharmacovigilance data are warranted to establish precise incidence estimates and identify clinically significant risk factors.

IMPLICATIONS FOR CLINICAL PRACTICE

This review's insights aroused clinical staff's attention and concern about cirAEs, potentially enhancing the quality of life of patients with cancer.

Blocking Tumoral Angiogenesis VEGF/VEGFR Pathway: Bevacizumab-20 Years of Therapeutic Success and Controversy

The "angiogenesis switch"-defined as the active process by which solid tumors develop their own circulation-plays an important role in both tumoral growth and propagation. As the malignant tumor grows and reaches a critical size, the metabolic needs as a function of an ever-increasing distance to the nearest emergent blood vessel, can no longer be covered by the microenvironment of the peritumoral tissue. Although a relatively discrete process, the "angiogenic switch" acts as a limiting stage of tumoral development present from the avascular hyperplasia phase to the vascularized neoplastic phase, providing support for tumor expansion and metastasis. Over time, research has focused on blocking the angiogenetic pathways (such as VEGF/VEGFR signaling axis) leading to the development of targeted therapeutic agents such as Bevacizumab. Objectives: We conducted a review of the molecular principles of tumoral angiogenesis and we tried to follow the history of Bevacizumab from its first approval for human usage 20 years ago to current days, focusing on the impact this agent had in solid tumor therapy. A comprehensive review of clinical trials pertaining to Bevacizumab (from the era of the preclinic trials leading to approval for human usage, to the more recent randomized trial focusing on combination targeted therapy) further details the role of this drug. We aimed to establish if this ancient drug continues to have a place in modern oncology. Conclusions: Bevacizumab, one of the first drugs targeting tumoral microenvironment, remains one of the most important oncologic agents blocking the VEGF/VEGFR angiogenic pathway. otherwise, history of 20 years marked by numerous controversies (ranging from methodological errors of clinical trials to withdrawal of approval for human usage in breast cancer patients, from discussions about severe side effects to resistance to therapy and limited efficacity), Bevacizumab continues to provide an optimal therapeutic option for many solid tumors that previously had little to no means of treatment, improving otherwise bleak outcomes. Even in the era of personalized precision oncology, Bevacizumab continues to be a key element in many therapeutic regimens both as monotherapy and in combination with newer targeted agents.

Efficacy and safety of immunotherapy in real-world patients with advanced non-small cell lung cancer

OBJECTIVE

The aim of this study was to explore the predictors of immunotherapy efficacy for advanced non-small cell lung cancer (NSCLC) in the real world and to analyze the clinical efficacy and safety of patients receiving immunotherapy for advanced NSCLC.

METHODS

Clinical pathological data from patients diagnosed with advanced NSCLC treated with immune checkpoint inhibitors (ICIs) were collected. Survival analysis and differential efficacy comparison of progression-free survival (PFS) was performed using the Kaplan-Meier method and Log-rank test. Univariate and multivariate analyses of PFS and objective response rate (ORR) were performed by Cox proportional risk regression models and logistic regression models to explore influence factors associated with the prognosis of immunotherapy.

RESULTS

(1) Overall, the median PFS (median PFS, mPFS) for 237 patients was 11.3 months (range: 8.5-14.1), the ORR was 55.7 %. Univariate and multivariate analyses of PFS in the overall population found that age ≥65 years, Eastern Cooperative Oncology Group (ECOG) physical status (PS) score of 0-1, clinical stage III, absence of liver metastases, immunotherapy combined with chemotherapy and prognostic nutritional index (PNI) ≥47.8 were independent predictors of longer PFS in immunotherapy-advanced NSCLC. Univariate and multifactorial logistic regression analysis of ORR in 237 patients suggested that ECOG PS score, number of ICI lines and prognostic nutritional index (PNI) were independent influence factors of ORR. (2) In the "stage IV, first-line, ECOG PS 0-1" subgroup, 106（106/237）patients had an mPFS of 10.9 months (range: 9.6-12.2) and an ORR of 59.4 %. Univariate and multivariate analyses of PFS in subgroups found that liver metastases, immunotherapy combined with chemotherapy and PNI were independent influencers of PFS. A univariate analysis of ORR found that only High-PNI was associated with longer PFS. (3) Additional factors affecting the efficacy were explored. A subgroup analysis among 64 (64/237) patients with accessible programmed death-ligand 1 (PD-L1) expression levels showed a trend towards a PFS benefit in patients with PD-L1 tumor cell proportion score (TPS) ≥ 50 % and TPS < 1 % compared to patients with PD-L1 TPS < 1 % (p=0.196); A subgroup analysis among 91 (91/237) patients with traceable genetic test results showed that patients with positive driver genes (KRAS/MET/RET/HER2/EGFR/ALK) had a shorter PFS than patients with negative driver genes (HR=1.712, 95 % CI: 0.994-2.947, p=0.048); Subgroup analyses of efficacy assessment showed significantly prolonged PFS in patients with an initial or best outcome assessment of complete response (CR) or partial remission (PR) compared with stable disease (SD) or progressive disease (PD) (P < 0.001). (4) Immune-related adverse events (irAEs) requiring pharmacological intervention or discontinuation were recorded. 61 (61/237) patients experienced irAEs during treatment. Grade 1∼2 adverse reactions occurred in 27.8 % of patients and grade ≥3 adverse reactions in 3.8 % of patients. There was no statistical difference in the occurrence (P=0.728) and severity (P=0.612) of adverse events between the ICIs.

CONCLUSION

This study reports the practical experience of ICIs in the treatment of NSCLC in China by analyzing the efficacy and safety of real-world advanced NSCLC treated with ICIs. The results were generally consistent with those of clinical trials, and the factors with the greatest impact on the efficacy of ICIs were ECOG PS, clinical stage, and PNI. Therefore, physicians can predict the future benefit of immunotherapy for NSCLC based on clinical prognostic indicators and make individualized treatment choices.

Serum VEGF-A as a biomarker for the addition of bevacizumab to chemo-immunotherapy in metastatic NSCLC

Anti-vascular endothelial growth factor (VEGF) agents in combination with immunotherapies have improved outcomes for cancer patients, but predictive biomarkers have not been elucidated. We report here a preplanned analysis in the previously reported APPLE study, a phase 3 trial evaluating the efficacy of the bevacizumab in combination with atezolizumab, plus platinum chemotherapy in metastatic, nonsquamous non-small cell lung cancer (NSCLC). We investigated the correlation of serum VEGF-A and its isoforms at baseline with treatment response by using an enzyme-linked immunosorbent assay. We reveal that the addition of bevacizumab significantly improves the progression-free survival in patients with the low VEGF-A level. Our results demonstrate that measuring serum VEGF-A or its isoforms may identify NSCLC patients who are likely to benefit from the addition of bevacizumab to immunotherapy. These assays are easy to measure and have significant potential for further clinical development.

Immunotherapy and the Tumor Microenvironment in Brain Metastases from Non-Small Cell Lung Cancer: Challenges and Future Directions

Brain metastases (BMs) are a relatively common and severe complication in advanced non-small cell lung cancer (NSCLC), significantly affecting patient prognosis. Metastatic tumor cells can alter the brain tumor microenvironment (TME) to promote an immunosuppressive state, characterized by reduced infiltration of tumor-infiltrating lymphocytes (TILs), diminished expression of programmed death-ligand 1 (PD-L1), and changes in other proinflammatory factors and immune cell populations. Microglia, the resident macrophages of the brain, play a pivotal role in modulating the central nervous system (CNS) microenvironment through interactions with metastatic cancer cells, astrocytes, and infiltrating T cells. The M2 phenotype of microglia contributes to immunosuppression in BM via the activation of signaling pathways such as STAT3 and PI3K-AKT-mTOR. Recent advances have enhanced our understanding of the immune landscape of BMs in NSCLC, particularly regarding immune evasion within the CNS. Current immunotherapeutic strategies, including immune checkpoint inhibitors, have shown promise for NSCLC patients with BM, demonstrating intracranial activity and manageable safety profiles. Future research is warranted to further explore the molecular and immune mechanisms underlying BM, aiming to develop more effective treatments.

Immunotherapy in advanced, KRAS G12C-mutant non-small-cell lung cancer: current strategies and future directions

Kirsten rat sarcoma (KRAS) mutations are present in up to 25% of non-small-cell lung cancer (NSCLC). KRAS G12C is the most common type of mutation, representing approximately half of the cases in KRAS-mutant NSCLC. Mutations in KRAS activate the RAF-MEK-ERK pathway, leading to increased cell proliferation and survival. Recent advances in drug development have led to the approval of KRAS G12C inhibitors sotorasib and adagrasib. This review explores the emerging therapeutic strategies in KRAS G12C-mutant NSCLC, including dual checkpoint blockade and combinations with checkpoint inhibitors, with a focus on the setting of advanced disease.

Healthcare resource utilization and associated cost in patients with metastatic non-small cell lung cancer treated in the immunotherapy era

BACKGROUND

Treatment approach for metastatic non-small cell lung cancer (mNSCLC) has revolutionized in the recent decade with the introduction of immunotherapy and targeted medications in first-line (1L) therapy. We present real-world data on clinical outcomes and direct healthcare resource utilization (HCRU) and cost in a 2.7-million-member Israeli health provider.

PATIENTS AND METHODS

Newly diagnosed mNSCLC patients between January 2017 and December 2020 were categorized by 1L treatment: platinum-based chemotherapy, targeted therapy, or immunotherapy. HCRU and costs were calculated based on the Ministry of Health Prices and were assessed at a minimum of 6 months' follow-up (cutoff: 30 June 2021).

RESULTS

A total of 886 patients were included in the study: 40.6% female, median age 68 years (IQR 61-74), 24.3% never smokers, 80.6% with adenocarcinoma, and 54% with a 0-1 performance status. The median follow-up was 27.12 months (95% CI, 24.7-29.6) and the median duration of first-line (1L) treatment was 2.3 months for platinum-based chemotherapy (n = 177), 12.3 months for targeted therapy (n = 255), and 4.8 months for immunotherapy (n = 463). The median overall survival was 9.09, 27.68, and 12.46 months, respectively. Total 1L costs were driven by radiotherapy for platinum-based chemotherapy and medication for targeted therapy or immunotherapy. Total costs for deceased patients over the entire follow-up were €121 155, €129 458, and €110 716, respectively.

CONCLUSION

The treatment of mNSCLC carries a high economic burden, primarily driven by first-line therapy, especially with targeted and immune therapies. Further studies are needed to evaluate the impact of innovative treatments on the disease management costs of mNSCLC.

Real-world data of first-line treatment with pembrolizumab for NSCLC with high PD-L1 expression in elderly patients: a subgroup analysis of HOT/NJLCG2001

BACKGROUND

In the first-line treatment of elderly patients with advanced-stage non-small cell lung cancer (NSCLC) with high programmed death-ligand 1 (PD-L1) expression (tumor proportion score ≥ 50%), this study aimed to determine whether pembrolizumab monotherapy (MONO) or pembrolizumab plus platinum-based chemotherapy (COMB) should be selected.

METHODS

We performed a retrospective multicenter study (sub-analysis of the HOT/NJLCG2001 trial) of 299 patients with NSCLC with high PD-L1 expression who received MONO or COMB as the first-line treatment between December 2018 and January 2020. We selected patients aged 75 years and older and assessed the clinical efficacy and toxicity.

RESULTS

In total, 81 (median age: 79 years) and 19 (median age: 76 years) patients received MONO and COMB, respectively. Twenty patients with a performance status (PS) score of 2-3 were enrolled in the MONO group. The median progression-free survival (PFS) was 7.8 and 8.9 months in the MONO and COMB groups, respectively. The median overall survival (OS) was 14.6 and 20.3 months, and the 2-year survival rates were 38.8 and 49.9%, respectively. Furthermore, 29.6% and 26.3% of patients discontinued treatment due to adverse events, respectively. In MONO, patients with PS 0-1 had a longer PFS (10.5 months) and OS (21.7 months) than those with PS 2-3 (0.7 and 1.6 months, respectively).

CONCLUSION

Some elderly patients with NSCLC and high PD-L1 expression might benefit from COMB; however, MONO is considered the preferred treatment. MONO may not be an effective or feasible treatment for patients with PS 2-3, even with high PD-L1 expression.

Nanomedicine Innovations for Lung Cancer Diagnosis and Therapy

Lung cancer remains a challenge within the realm of oncology. Characterized by late-stage diagnosis and resistance to conventional treatments, the currently available therapeutic strategies encompass surgery, radiotherapy, chemotherapy, immunotherapy, and biological therapy; however, overall patient survival remains suboptimal. Nanotechnology has ushered in a new era by offering innovative nanomaterials with the potential to precisely target cancer cells while sparing healthy tissues. It holds the potential to reshape the landscape of cancer management, offering hope for patients and clinicians. The assessment of these nanotechnologies follows a rigorous evaluation process similar to that applied to chemical drugs, which includes considerations of their pharmacokinetics, pharmacodynamics, toxicology, and clinical effectiveness. However, because of the characteristics of nanoparticles, standard toxicological tests require modifications to accommodate their unique characteristics. Effective therapeutic strategies demand a profound understanding of the disease and consideration of clinical outcomes, physicochemical attributes of nanomaterials, nanobiointeractions, nanotoxicity, and regulatory compliance to ensure patient safety. This review explores the promise of nanomedicine in lung cancer treatment by capitalizing on its unique physicochemical properties. We address the multifaceted challenges of lung cancer and its tumor microenvironment and provide an overview of recent developments in nanoplatforms for early diagnosis and treatment that can enhance patient outcomes and overall quality of life.

Revolutionary Cancer Therapy for Personalization and Improved Efficacy: Strategies to Overcome Resistance to Immune Checkpoint Inhibitor Therapy

Cancer remains a significant public health issue worldwide, standing as a primary contributor to global mortality, accounting for approximately 10 million fatalities in 2020 [...].

[ALK rearrangement in non-small cell lung cancer]

The discovery of ALK gene rearrangement in 3 to 5% of non-small cell lung carcinomas has revolutionized our understanding and therapeutic approach of these cancers. This oncogenic driver is associated with specific clinical and biological features is associated with specific clinical and biological features, mainly affecting young and never-smoker patients, with a particular tropism for brain metastases. The development of ALK tyrosine kinase inhibitors has transformed patient outcomes, with remarkable efficacy of latest-generation molecules, particularly in controlling brain metastases. However, the emergence of complex resistance mechanisms, whether ALK-dependent or ALK-independent, remains a major challenge. The comprehensive understanding of these resistance mechanisms now guides the development of next-generation inhibitors and innovative therapeutic strategies, paving the way for increasingly personalized precision medicine.

Prediction of checkpoint inhibitor immunotherapy efficacy for cancer using routine blood tests and clinical data

Predicting whether a patient with cancer will benefit from immune checkpoint inhibitors (ICIs) without resorting to advanced genomic or immunologic assays is an important clinical need. To address this, we developed and evaluated SCORPIO, a machine learning system that utilizes routine blood tests (complete blood count and comprehensive metabolic profile) alongside clinical characteristics from 9,745 ICI-treated patients across 21 cancer types. SCORPIO was trained on data from 1,628 patients across 17 cancer types from Memorial Sloan Kettering Cancer Center. In two internal test sets comprising 2,511 patients across 19 cancer types, SCORPIO achieved median time-dependent area under the receiver operating characteristic curve (AUC(t)) values of 0.763 and 0.759 for predicting overall survival at 6, 12, 18, 24 and 30 months, outperforming tumor mutational burden (TMB), which showed median AUC(t) values of 0.503 and 0.543. Additionally, SCORPIO demonstrated superior predictive performance for predicting clinical benefit (tumor response or prolonged stability), with AUC values of 0.714 and 0.641, compared to TMB (AUC = 0.546 and 0.573). External validation was performed using 10 global phase 3 trials (4,447 patients across 6 cancer types) and a real-world cohort from the Mount Sinai Health System (1,159 patients across 18 cancer types). In these external cohorts, SCORPIO maintained robust performance in predicting ICI outcomes, surpassing programmed death-ligand 1 immunostaining. These findings underscore SCORPIO's reliability and adaptability, highlighting its potential to predict patient outcomes with ICI therapy across diverse cancer types and healthcare settings.

[First line treatment of non-oncogene-addicted metastatic non-small cell lung cancer]

Since 2017, anti-PD-(L)1 immunotherapy has been the cornerstone of first-line treatment for stage IV non-oncogene-addicted non-small cell lung cancer. Its phase I development has established that the level of PD-L1 expression by tumor cells is predictive of response rate and progression-free survival. Above 50%, it makes chemotherapy not mandatory, with a median survival for pembrolizumab monotherapy of around 26 months and five-year survival of 32%. Large phase III studies have also validated the combination of anti-PD-(L)1 immunotherapy and platinum-based chemotherapy regardless of PD-L1 level of expression, increasing five-year survival from 10% to 18%. Dual immunotherapy combining anti-CTLA-4 and anti-PD-(L)1 might be interesting, especially in PD-L1 negative tumors, but is not available in France. Treatment personalization, particularly in the case of PD-L 1 expression >50%, should be based on response and non-response factors to immunotherapy, including patient-related factors such as performans status, age, smoking status, as well as tumor-related factors such as disease aggressiveness, tumor volume, mutational profile, along with concomitant medications. The optimal duration of immunotherapy is uncertain and arbitrarily set at two years. Many options are currently being explored to improve first-line treatment outcomes, as the majority of patients experience resistance to immunotherapy.

Development of a Microvessel Density Gene Signature and Its Application in Precision Medicine

SIGNIFICANCE

A novel gene signature for MVD was developed. This MVD gene score enables the estimation of MVD, reflecting the sensitivity to antiangiogenic inhibitors, in transcriptomic datasets. We demonstrated the utility of the MVD gene score together with a T cell-inflamed gene signature for potential future use as a clinical biomarker.

Clinical efficacy and safety of immune checkpoint inhibitors plus anlotinib as secondline or subsequent therapy in extensive stage small cell lung cancer: a retrospective study

BACKGROUND

Treatments are limited for extensive stage small cell lung cancer (ES-SCLC) patients in secondline or subsequent setting. This study aimed to explore the clinical efficacy and safety of immune checkpoint inhibitors (ICIs) plus anlotinib as secondline or subsequent therapy in ES-SCLC.

METHODS

We retrospectively analyzed 116 patients with ES-SCLC at Shandong Provincial Qianfoshan Hospital between January 2019 and March 2024. According to the different therapy regimes, they were divided into three groups, ICI plus anlotinib as secondline or subsequent therapy group (ICI + anlotinib group), single ICI as secondline or subsequent therapy group (single ICI therapy group), single chemotherapy as secondline therapy group (single chemotherapy group). Kaplan-Meier method was used to compare the progression-free survival (PFS) and the overall survival time (OS) among these three groups. Cox regression analysis was used to analyze different factors which correlated to PFS and OS. The adverse events were assessed according to the Common Terminology Criteria for Adverse Events version 5.0.

RESULTS

Kaplan-Meier analysis showed that patients in ICI + anlotinib group had a longer PFS and OS compared to patients in single ICI therapy group (median PFS [mPFS]: 6.7 months vs. 4.6 months, P = 0.007; median OS [mOS]:12.4 months vs. 8.4 months, P = 0.041) and single chemotherapy group (mPFS: 6.7 months vs. 3.0 months, P < 0.001; mOS: 12.4 months vs. 7.2 months, P = 0.002). The Cox regression analysis showed that the Eastern Cooperative Oncology Group performance status (ECOG PS), liver metastasis, brain metastasis and treatment regimes were independent predictors that affecting the PFS and OS of all the enrolled patients. The common adverse events (AEs) were wleukopenia and fatigue. There was no significant statistical difference in other AEs among the three groups except for leukopenia.

CONCLUSION

ICI + anlotinib as secondline or subsequent therapy has better efficacy than single ICI group and single chemotherapy group and with tolerable toxicities for patients with ES-SCLC.

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.

Safety, Pharmacokinetics, and Pharmacodynamics Evaluation of Ivonescimab, a Novel Bispecific Antibody Targeting PD-1 and VEGF, in Chinese Patients With Advanced Solid Tumors

BACKGROUND

Ivonescimab (AK112) is a first-in-class bispecific antibody that simultaneously targets programmed death-1 (PD-1) and vascular endothelial growth factor (VEGF) with cooperative binding. We report the safety, pharmacokinetics (PK), and pharmacodynamics (PD) profiles of ivonescimab in patients suffered from advanced solid tumors.

METHODS

A multicenter, open-label, dose-escalation, phase I study was conducted in five hospitals in China. Ivonescimab was used as a monotherapy. The dose of ivonescimab intravenously administered was 3, 5, 10, 20, and 30 mg/kg every 2 weeks (Q2W), and 10 and 20 mg/kg every 3 weeks (Q3W). Safety, PK, and PD of ivonescimab were evaluated.

RESULTS

A total of 59 patients treated in the study. Only one dose-limiting toxicity (DLT) occurred in 1 out of 9 patients in the 10 mg/kg Q2W cohort, indicating that no maximum tolerated dose was reached. Among the participants, 53 patients (89.8%) experienced treatment-related adverse events (TRAEs), with the most common being proteinuria (33.9%), aspartate aminotransferase elevation (27.1%), white blood cell count decrease (22.0%), alanine aminotransferase elevation (20.3%), and anemia (20.3%). Fourteen patients (23.7%) had ≥ Grade 3 TRAEs, and 7 patients (11.9%) experienced serious TRAEs. Notably, there were no reported deaths associated with the TRAEs, and no dose-dependent increase in adverse events was observed. The half-life of ivonescimab ranged from 5.0 to 7.3 days following single-dose administration across all dose levels. The serum concentrations of ivonescimab increased with escalating doses in an approximately dose-proportional manner. Following multiple doses, the accumulation ratio ranged from 1.1 to 1.7, suggesting mild accumulation of ivonescimab. The steady state was achieved after 5 doses. Ivonescimab occupancy on PD-1 sustained over 80% across the treatment period. Serum VEGF level was rapidly down-regulated after each administration.

CONCLUSIONS

In patients with advanced solid tumors, ivonescimab monotherapy was well-tolerated and demonstrated a linear PK characteristics. PD profiles showed the promising potential of ivonescimab for the management of advanced solid tumors.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04597541).

Clonal driver neoantigen loss under EGFR TKI and immune selection pressures

Neoantigen vaccines are under investigation for various cancers, including epidermal growth factor receptor (EGFR)-driven lung cancers1,2. We tracked the phylogenetic history of an EGFR mutant lung cancer treated with erlotinib, osimertinib, radiotherapy and a personalized neopeptide vaccine (NPV) targeting ten somatic mutations, including EGFR exon 19 deletion (ex19del). The ex19del mutation was clonal, but is likely to have appeared after a whole-genome doubling (WGD) event. Following osimertinib and NPV treatment, loss of the ex19del mutation was identified in a progressing small-cell-transformed liver metastasis. Circulating tumour DNA analyses tracking 467 somatic variants revealed the presence of this EGFR wild-type clone before vaccination and its expansion during osimertinib/NPV therapy. Despite systemic T cell reactivity to the vaccine-targeted ex19del neoantigen, the NPV failed to halt disease progression. The liver metastasis lost vaccine-targeted neoantigens through chromosomal instability and exhibited a hostile microenvironment, characterized by limited immune infiltration, low CXCL9 and elevated M2 macrophage levels. Neoantigens arising post-WGD were more likely to be absent in the progressing liver metastasis than those occurring pre-WGD, suggesting that prioritizing pre-WGD neoantigens may improve vaccine design. Data from the TRACERx 421 cohort3 provide evidence that pre-WGD mutations better represent clonal variants, and owing to their presence at multiple copy numbers, are less likely to be lost in metastatic transition. These data highlight the power of phylogenetic disease tracking and functional T cell profiling to understand mechanisms of immune escape during combination therapies.

Oncogenic Mutations and the Tumor Microenvironment: Drivers of Non-Small Cell Lung Cancer Progression

BACKGROUND/OBJECTIVES

Non-small cell lung cancer (NSCLC) is a major cause of cancer-related deaths globally. The study focuses on understanding the interplay between genetic mutations, cancer stem cells (CSCs), and the tumor microenvironment (TME) in driving NSCLC progression, resistance to therapies, and relapse.

METHODS

A systematic search was conducted in PubMed and Scopus databases to identify significant and valuable studies relevant to NSCLC, focusing on genetic mutations, CSCs, and the TME. Articles were selected based on their relevance, methodological severity, date of publication, and scientific soundness related to NSCLC biology and therapeutic strategies. This review synthesized findings from these sources to highlight key mechanisms and potential therapeutic interventions.

RESULTS

Mutations in critical genes in KRAS, EGFR, TP53, and other key genes interfere with stem cell regulation, promoting CSC-like behavior, resistance to therapy, and immune evasion. The tumor microenvironment (TME), including immune cells, fibroblasts, and extracellular matrix components, further supports tumor growth and reduction in treatment efficacy. Promising strategies, including CSC targeting, TME modulation, and the development of novel biomarkers, have shown potential in preclinical and clinical studies.

CONCLUSIONS

The association between genetic alterations, CSCs, the TME, and other cellular pathways-including cell metabolism and immune evasion-plays a crucial role in therapy resistance, highlighting the need for comprehensive treatment strategies. The combination of genomic profiling with TME-targeting therapies could lead to personalized treatment approaches, offering hope for better clinical outcomes and reduced mortality in NSCLC patients.

The biological macromolecules constructed Matrigel for cultured organoids in biomedical and tissue engineering

Matrigel is the most commonly used matrix for 3D organoid cultures. Research on the biomaterial basis of Matrigel for organoid cultures is a highly challenging field. Currently, many studies focus on Matrigel-based biological macromolecules or combinations to construct natural Matrigel and synthetic hydrogel scaffolds based on collagen, peptides, polysaccharides, microbial transglutaminase, DNA supramolecules, and polymers for organoid culture. In this review, we discuss the limitations of both natural and synthetic Matrigel, and describe alternative scaffolds that have been employed for organoid cultures. The patient-derived organoids were constructed in different cancer types and limitations of animal-derived organoids based on the hydrogel or Matrigel. The constructed techniques utilizing 3D bioprinting platforms, air-liquid interface (ALI) culture, microfluidic culture, and organ-on-a-chip platform are summarized. Given the potential of organoids for a wide range of therapeutic, tissue engineering and pharmaceutical applications, it is indeed imperative to develop defined and customized hydrogels in addition to Matrigel.

Efficacy and safety of immune checkpoint inhibitors in elderly patients with advanced non-small cell lung cancer: a systematic review and meta-analysis

Background

Immune checkpoint inhibitors (ICIs) are the preferred treatments for advanced non-small cell lung cancer (NSCLC) without targetable oncogene alterations. However, evidence in the elderly population (aged ≥ 65 years) remains limited.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases for eligible publications until September 30, 2024. The primary outcome of interest was overall survival (OS). A random-effects model was used for the statistical analysis.

Findings

A total of 35 phase 3 randomized controlled trials (RCTs) involving 9788 patients and 64 real-world studies involving 37,111 patients were included. Results from phase 3 RCTs revealed that ICIs significantly improved OS (hazard ratio [HR] = 0.78, 95% confidence interval [CI]: 0.74-0.82) and progression-free survival (PFS) (HR = 0.67, 95% CI: 0.60-0.75) compared to chemotherapy. The association between ICIs and improved OS was independent of patient characteristics (race and histological type) or treatment-related factors (ICI drug type, treatment mode, and treatment line). However, significantly prolonged OS was not observed in subgroups of aged ≥ 75 years and PD-L1 < 1%. In real-world studies, the pooled median OS of ICIs were 11.8 months (95% CI: 11.2-12.4); Eastern Cooperative Oncology Group (EOCG) score, histological type, PD-L1 status, with immune-related adverse events (irAEs), and treatment mode were predictive for OS; rates of irAEs and discontinuation were numerically higher for combination therapy vs. monotherapy.

Interpretation

ICIs are associated with a significant improvement in OS and PFS compared to chemotherapy in elderly patients with advanced NSCLC. Nevertheless, some patient characteristics such as aged ≥ 75 years, ECOG score ≥ 2, and PD-L1 < 1% seem to have a negative impact on the efficacy of ICIs, while these findings require further validation in large RCTs.

Funding

None.

Taxane-Associated Acute Pain Syndrome: a Review of its Features and Management

OPINION STATEMENT

Taxane-associated acute pain syndrome (T-APS) is one of the most common adverse effects of taxane treatment and significantly reduces the quality of life and activities of daily living of patients. T-APS is recognized as myalgia and arthralgia, which generally appear 1-3 days after taxane administration and last for approximately 7 days, at a wide range of sites. Recently, T-APS has been suggested to be not only an acute symptom but also a chronic symptom associated with chemotherapy-induced peripheral neuropathy (CIPN). The reported incidence of T-APS varies among studies, possibly owing to differences in observation points, evaluation methods, taxane administration methods, concomitant medications, or patient factors. Several factors, such as high taxane dose, paclitaxel use, metastatic setting, breast cancer, younger age, and co-administration of pegfilgrastim, are associated with symptom development. Several findings regarding T-APS management, such as prophylaxis using corticosteroids, Shakuyaku-Kanzo-to, and non-steroidal anti-inflammatory drugs (NSAIDs), are present. Corticosteroids for several days after taxane administration dose-dependently prevents and attenuates T-APS although we should be cautious about its longer administration. Prophylactic administration of Shakuyaku-Kanzo-to, a herbal compound, may be useful, although prescriptions are only available in limited areas. Etoricoxib, a selective cyclooxygenase-2 inhibiting NSAID, also reduces the incidence and severity of T-APS. Additionally, its prophylactic administration decreases CIPN. In contrast, evidence of symptomatic medication is limited. Taxanes are key chemotherapeutic agents used in the treatment of several types of cancer; therefore, further assessment of mechanisms of action and treatment of T-APS is necessary.

Pembrolizumab and Pemetrexed for Older Patients With Nonsquamous NSCLC and Programmed Cell Death-Ligand 1 Tumor Proportion Scores of Less Than 50

Introduction

Pembrolizumab with pemetrexed and cisplatin/carboplatin is an approved first-line treatment for metastatic nonsquamous NSCLC. Nevertheless, its efficacy and safety in patients aged 75 years and above remain unclear. We assessed the efficacy and safety of pembrolizumab with pemetrexed in patients with programmed cell death-ligand 1 expression tumor proportion scores of less than 50%.

Methods

This multicenter, open-label, phase 2 trial involved 42 institutions across Japan. Eligible participants had metastatic or recurrent nonsquamous NSCLC without sensitizing EGFR or ALK alterations, were aged 75 years or above, had a programmed cell death-ligand 1 tumor proportion score of less than 50%, had not undergone systemic chemotherapy, and had an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients received pemetrexed (500 mg/m2) and pembrolizumab (200 mg) on day 1 of each 21-day cycle. The primary endpoint was the objective response rate. The secondary endpoints included progression-free survival, overall survival, and safety.

Results

Forty-nine patients were enrolled in this study between July 2020 and May 2022. The objective response rate was 36.7% (95% confidence interval [CI]: 23.4%-51.7%). The disease control rate was 65.3% (95% CI: 50.4-78.3%). The median progression-free survival was 7.6 months (95% CI: 4.8-16.2), and the median overall survival was 19.4 months (95% CI: 11.8 mo-unreached). The most common grade 3 or 4 adverse events were neutropenia (31.3%), leukopenia (20.8%), and anemia (12.5%). No treatment-related deaths occurred during this period.

Conclusions

Pembrolizumab with pemetrexed is a promising first-line treatment option for older patients with metastatic nonsquamous NSCLC. This trial was registered at ClinicalTrials.gov (NCT04396457) and the Japan Registry of Clinical Trials (jRCTs041200012).

Durvalumab Versus Chemotherapy as First-line Treatment for Metastatic NSCLC With Tumor PD-L1 Expression of 25% or Higher: Results From the Randomized Phase 3 PEARL Study

INTRODUCTION

PEARL (NCT03003962) is an open-label, phase 3 study comparing first-line durvalumab monotherapy with chemotherapy in patients with metastatic NSCLC (mNSCLC [EGFR/ALK wild type]) with programmed cell death ligand 1 (PD-L1) tumor cell (TC) membrane expression status of 25% or higher. We report the final analysis of PEARL.

METHODS

Adults (N = 669) with previously untreated stage IV mNSCLC were randomized (1:1) to durvalumab 20 mg/kg every four weeks or chemotherapy every three weeks for four to six cycles. The dual primary endpoints were overall survival (OS) in the population with PD-L1 TC of 25% or higher and OS in the population at low risk of early mortality (LREM) with PD-L1 TC of 25% or higher.

RESULTS

Durvalumab was associated with a numerical reduction in the risk of death versus chemotherapy in the 25% and higher PD-L1 TC population (OS hazard ratio [HR] = 0.84, 95% confidence interval [CI]: 0.71-0.99, p = 0.037; median OS 14.6 months, 95% CI: 12.2-16.9 versus 12.8 months, 95% CI: 10.1-14.7, respectively). In the 25% and higher PD-L1 TC low risk of early mortality population the OS hazard ratio for durvalumab versus chemotherapy was 0.96 (95% CI: 0.79-1.15, p = 0.628); median OS 14.6 months (95% CI: 12.6-17.2) versus 15.0 months (95% CI: 13.1-16.8), respectively. In the safety population, the incidence of grade 3 or 4 treatment-related adverse events was 15.5% (durvalumab) and 45.9% (chemotherapy).

CONCLUSIONS

Durvalumab did not statistically significantly improve OS versus chemotherapy as first-line treatment in patients with mNSCLC and 25% and higher PD-L1 TC. The numerical improvement in OS was consistent with previous studies of first-line immune checkpoint inhibitor monotherapy in patients with mNSCLC.

Immunotherapy for Elderly Patients with Advanced Non-Small Cell Lung Cancer: Challenges and Perspectives

Lung cancer, a leading cause of cancer-related mortality, disproportionately affects the elderly, who face unique challenges due to comorbidities and reduced organ function. Immune checkpoint inhibitors (ICIs) offer a more tolerable alternative to chemotherapy, but their efficacy and safety in elderly non-small cell lung cancer (NSCLC) patients remain underexplored due to limited representation in clinical trials. A narrative literature review was conducted using PubMed, Embase, and the Cochrane Library to evaluate studies on elderly NSCLC patients (≥65 years) treated with ICIs. Key outcomes assessed included overall survival, progression-free survival, response rates, treatment-related adverse events, and the influence of immunosenescence on treatment efficacy. The review highlighted evidence supporting the efficacy and safety of ICIs in elderly NSCLC patients, particularly those with good performance status. Age-related immunosenescence may affect outcomes, emphasizing the need for individualized treatment. Limited data suggest ICIs alone may be preferable to chemo-immunotherapy for patients over 75 years. However, the exclusion of elderly patients from clinical trials and methodological limitations reduces the generalizability of these findings. ICIs hold promise for advanced NSCLC in older adults, but tailored approaches and greater elderly inclusion in trials are needed to optimize outcomes.

Severe thyroiditis induced by sintilimab monotherapy in a patient with non-small cell lung cancer: a case report and literature review

Thyroid dysfunction is a common immune-related adverse event (irAE) associated with immune checkpoint inhibitors (ICIs) that target PD-1, PD-L1, and CTLA-4. Nevertheless, the incidence of severe cases, defined as grade 3 or higher, remains rare. This report presents a detailed case study of severe thyroiditis in a patient with non-small cell lung cancer (NSCLC) who developed grade 3 thyroiditis following a single cycle of sintilimab monotherapy. The clinical presentation in this patient was remarkable for its early onset, occurring one week after the initiation of sintilimab therapy, and for its severe manifestations. During hospitalization, a prompt and accurate differential diagnosis was performed. Sintilimab treatment was discontinued, and the patient was promptly started on high-dose glucocorticoids, with a tapering schedule implemented as the condition improved or reached Common Terminology Criteria for Adverse Events (CTCAE) grade 1 or lower. The patient subsequently developed overt hypothyroidism, necessitating the initiation of thyroxine replacement therapy. Furthermore, we provide a comprehensive review of the mechanisms and risk factors associated with thyroid dysfunction immune-related adverse events (TD-irAEs). It is imperative for clinicians to meticulously monitor the clinical symptoms exhibited by patients. For those presenting with symptoms, prompt diagnosis and appropriate symptomatic management are essential. Additionally, regular thyroid function testing is recommended for high-risk patients, and we advocate for the assessment of baseline levels of thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TGAb) prior to initiating ICI treatment.

Prolgolimab with chemotherapy as first-line treatment for advanced non-squamous non-small-cell lung cancer

BACKGROUND

Prolgolimab is an IgG1 anti-PD-1 monoclonal antibody with the Fc-silencing 'LALA' mutation. The phase III DOMAJOR study assessed efficacy and safety of prolgolimab in combination with pemetrexed and platinum-based chemotherapy vs placebo in combination with pemetrexed and platinum-based chemotherapy as first-line treatment for advanced non-small cell lung cancer (NSCLC).

METHODS

292 patients with advanced non-squamous NSCLC were randomized 1:1 to receive 4 cycles of pemetrexed, platinum-based drug and either prolgolimab (3 mg/kg Q3W) or placebo followed by prolgolimab/placebo with pemetrexed until disease progression or toxicity (≤36 months). The primary endpoint was overall survival (OS).

RESULTS

After a median follow-up of 18 months, the median OS was not reached (95 % CI, 22.28 - NA) in the prolgolimab-combination group vs 14.6 months (95 % CI, 11.73 - 19.15) in the placebo-combination group (HR, 0.51; 95 % CI, 0.35 - 0.73, p = 0.0001). The OS improvement was independent of PD-L1 status. Median progression-free survival (PFS) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1) was 7.7 months in the prolgolimab-combination group and 5.5 months in the placebo-combination group (HR, 0.65; 95 % CI, 0.49 - 0.85, p = 0.0004). The only adverse events that were reported in at least 10 % of the patients that were significantly more frequent in the prolgolimab-combination group were blood creatinine increased and dyspnoea.

CONCLUSION

Among patients with advanced NSCLC the addition of prolgolimab to pemetrexed and a platinum-based drug increased OS and PFS, with no new safety concerns. This benefit was retained in patients with PD-L1 negative tumors. (ClinicalTrials.gov, NCT03912389).

Resistance to immunotherapy in non-small cell lung cancer: Unraveling causes, developing effective strategies, and exploring potential breakthroughs

Over the last two decades, advancements in deciphering the intricate interactions between oncology and immunity have fueled a meteoric rise in immunotherapy for non-small cell lung cancer, typified by an explosive growth of immune checkpoint inhibitors. However, resistance to immunotherapy remains inevitable. Herein we unravel the labyrinthine mechanisms of resistance to immunotherapy, characterized by their involvement of nearly all types of cells within the body, beyond the extrinsic cancer cells, and importantly, such cells are not only (inhibitory or excitatory, or both) signal recipients but also producers, acting in a context-dependent manner. At the molecular level, these mechanisms underlie genetic and epigenetic aberrations, which are regulated by or regulate various protein kinases, growth factors, and cytokines with inherently dynamic and spatially heterogeneous properties. Additionally, macroscopic factors such as nutrition, comorbidities, and the microbiome within and around organs or tumor cells are involved. Therefore, developing therapeutic strategies combined with distinct action informed by preclinical, clinical, and real-world evidence, such as radiotherapy, chemotherapy, targeted therapy, antibody-drug conjugates, oncolytic viruses, and cell-based therapies, may stand as a judicious reality, although the ideality is to overcome resistance point-by-point through a novel drug. Notably, we highlight a realignment of treatment aims, moving the primary focus from eliminating cancer cells -- such as through chemotherapy and radiotherapy -- to promoting immune modulation and underscore the value of regulating various components within the host macro- or micro-environment, as their effects, even if seemingly minimal, can cumulatively contribute to visible clinical benefit when applied in combination with ICIs. Lastly, this review also emphasizes the current hurdles scattered throughout preclinical and clinical studies, and explores evolving directions in the landscape of immunotherapy for NSCLC.