Overall Survival with Osimertinib in Untreated, EGFR-Mutated Advanced NSCLC

Comparison of first-generation EGFR-TKIs combined with low-dose bevacizumab versus osimertinib in untreated advanced EGFR-mutated NSCLC

BACKGROUND

This study aimed to compare the efficacy of first-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) combined with low-dose bevacizumab(7.5 mg/kg) versus osimertinib as first-line treatment in patients with advanced EGFR-mutated non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

A total of 161 patients with advanced NSCLC harboring EGFR mutations, who received first-line treatment at Shanghai Chest Hospital between July 2017 and July 2023, were enrolled in this study. Among them, 78 patients were treated with a combination of first-generation EGFR-TKIs and bevacizumab (7.5 mg/kg), constituting the bevacizumab plus TKI (A + T) group. The remaining 83 patients received osimertinib monotherapy (80 mg daily), forming the osimertinib group.

RESULTS

The objective response rate (ORR) was 65.4% (51/78) in the A + T group and 68.7% (57/83) in the osimertinib group (p = 0.657). Despite the potentially poorer baseline conditions of patients in the osimertinib group, the median progression-free survival (PFS) was 16.59 months (95% CI: 14.39-18.80) in the A + T group compared to 16.82 months (95% CI: 13.76-19.89) in the osimertinib group (p = 0.792). Preliminary overall survival (OS) analysis indicated a median OS of 51.75 months (95% CI: 41.63-61.86) in the A + T group versus 35.55 months (95% CI: 22.32-48.77) in the osimertinib group (p = 0.010), however, the OS data are not yet mature.

CONCLUSION

Although osimertinib remains the preferred first-line treatment for advanced NSCLC with EGFR mutations, combining first-generation EGFR-TKIs with low-dose bevacizumab may be a viable alternative for certain patients.

Progression and expansion of ALK inhibitors against NSCLC: A dual target approach

ALK gene is a member of the tyrosine kinase receptor family found on chromosome 2 (2p23) that plays an important role in the progression of the non-small cell lung cancer (NSCLC). Since the ALK inhibitors such as Crizotinib, Ceritinib, Brigatinib, Alectinib and Lorlatinib, was endorsed for the treatment of advanced NSCLC linked to ALK gene rearrangement. But eventually, patients become resistant to the medication, which will result in treatment failure. However, treatment for NSCLC could be greatly advanced by the development of dual inhibitors that target ALK in addition to other oncogenic pathways like ROS1, c-MET, EGFR, etc. These strategies seek to improve therapy efficacy, address resistance mechanisms, and provide treatment alternatives for patients with intricate molecular profiles. The aim of this review is to summarize the introduction to ALK and the synergy between ALK and other anti-tumor targets, recent developments in the synthesis of various dual inhibitors of the ALK. We also thoroughly discussed their design concepts, structure-activity relationships (SARs), preclinical and clinical data as well as in silico studies to provide ideas for further development of novel ALK based dual inhibitors.

Efficacy and safety of furmonertinib in patients with EGFR‑mutant advanced lung adenocarcinoma after failure of multiple lines of therapy: A single‑center retrospective study

Currently, treatments for patients with non-small cell lung cancer harboring epidermal growth factor receptor (EGFR) mutations are limited after receiving multiple lines of therapy. Furmonertinib, a newly developed third-generation EGFR-tyrosine kinase inhibitor (TKI), has shown potential as a subsequent treatment. To explore efficacy and safety of furmonertinib, the present retrospective study analyzed patients with EGFR-mutant advanced lung adenocarcinoma (LUAD) who received furmonertinib after the failure of multiple lines of therapy at the China-Japan Friendship Hospital (Beijing, China) between December 2021 and April 2024. Data on patient demographics, treatment efficacy and safety outcomes were assessed until disease progression. A total of 25 patients with advanced LUAD were retrospectively included in the analysis. Among them, 15 (60.0%) harbored exon 19del, whilst 10 (40.0%) had exon21 L858R mutations. Pre-treatment genetic testing was performed in 14 patients (56.0%). Prior to furmonertinib therapy, 17, 5 and 19 patients had previously received first-, second- and third-generation EGFR-TKIs, respectively. The median line of treatment before furmonertinib was 3. The median progression-free survival was 5.73 (95% confidence interval, 4.30-not reached) months. The objective response rate was 16.0% (n=4) and the disease control rate was 88.0% (n=22). A total of 18 (72.0%) patients experienced at least one adverse event (AE). The rate of AEs was 80.0% (n=20) for grade 1-2, and 20.0% (n=5) for grade 3-4 AEs. No AEs led to treatment discontinuation, dose reductions or death. In conclusion, furmonertinib is a viable treatment option for patients with EGFR-mutant advanced LUAD after the failure of multiple lines of therapy, even after resistance to treatment with third-generation EGFR-TKIs targeted agents. However, further large-scale clinical studies are warranted to validate these findings.

Jaceosidin overcomes osimertinib resistance in lung cancer by inducing G2/M cycle arrest through targeting DDB1

BACKGROUND

Osimertinib is a third-generation Epidermal Growth Factor Receptor (EGFR) tyrosine kinase inhibitor (TKI) widely used to treat advanced non-small cell lung cancer with EGFR mutations. However, resistance to osimertinib frequently develops, limiting its long-term effectiveness.

PURPOSE

This study aimed to establish a lung cancer TKI-resistant model and identify Traditional Chinese Medicine (TCM) components that could reverse TKI resistance, enhancing lung cancer sensitivity to targeted therapies, while exploring the underlying molecular mechanisms.

MATERIALS AND METHODS

Osimertinib-resistant cell lines and organoids were developed using a dose-escalation approach. A screen of 302 traditional Chinese medicine monomers revealed compounds that increased sensitivity to osimertinib. RNA sequencing and limited proteolysis coupled with small molecule mapping were employed to investigate the molecular mechanisms by which jaceosidin reverses resistance. The efficacy of the jaceosidin and osimertinib combination was confirmed in cell lines, organoids, and a mouse model.

RESULTS

The osimertinib-resistant lung cancer model was successfully established, and 12 compounds were identified that enhanced the sensitivity of resistant cells to osimertinib. Among these, Jaceosidin, a flavonoid compound derived from Eupatorium lindleyanum DC., was confirmed to notably increase osimertinib sensitivity. Mechanistic studies, including limited proteolysis and RNA interference analysis, demonstrated that Jaceosidin directly interacts with Damage Specific DNA Binding Protein 1 (DDB1), promoting its protein expression and downregulating CDK1/Cyclin B1 levels. This interaction induced G2/M cell cycle arrest, thereby sensitizing lung cancer cells to osimertinib. Furthermore, both in vitro and in vivo experiments confirmed that the combination of Jaceosidin and osimertinib significantly inhibited tumor growth in osimertinib-resistant models.

CONCLUSION

These findings offer new insights into the role of DDB1 in overcoming osimertinib resistance and suggest that combining jaceosidin with osimertinib may serve as a promising therapeutic strategy to enhance the efficacy of EGFR-TKIs treatment in resistant Non-small Cell Lung Cancer (NSCLC).

A novel MMP-9 inhibitor exhibits selective inhibition in non-small-cell lung cancer harboring EGFR T790M mutation by blocking EGFR/STAT3 signaling pathway

The T790M secondary mutation in EGFR confers therapeutic resistance to EGFR-TKIs, leading to poor outcomes. Non-small-cell lung cancer (NSCLC) harboring EGFR T790M mutation is incurable and there is an urgent need for improved therapeutics. Here we report the identification of a small compound, MG-3C, that kills NSCLC cells with T790M mutation while sparing lung cancer cells without T790M mutation. We found that MG-3C activity targets EGFR-STAT3 signaling pathway in NSCLC through direct inhibition of matrix metalloproteinase 9 (MMP-9), ultimately leading to G2/M phase arrest, growth inhibition and apoptosis. Compared with the reported MMP-9 inhibitor Ilomastat, MG-3C shows high anticancer activity and affinity for targets. MG-3C forms hydrogen bonds with the ASP-113, ASP-201 and HIS-203 amino acid residues of MMP-9 with a docking fraction of -9.04 kcal/mol, while Ilomastat forms hydrogen bonds with the GLN-169, ASP-201 and HIS-203 amino acid residues of MMP-9 with a docking fraction of -5.98 kcal/mol. The spatial structure composed of ASP-113, ASP-201, and HIS-203 of MMP-9 provides a new coordinate for the design of MMP-9 inhibitors. Most importantly, subcutaneous and oral administration of MG-3C elicit dramatic regression of NSCLC xenograft tumors harboring T790M mutation as well as favorable biosafety profile in vivo, suggesting that MG-3C may be a potential candidate for NSCLC harboring T790M mutation.

A clinical review on third and fourth generation EGFR tyrosine kinase inhibitors for the treatment of non-small cell lung cancer

"Epidermal growth factor receptor (EGFR)" mutations are pivotal in the pathogenesis of "Non-Small Cell Lung Cancer (NSCLC)," which is associated with high morbidity and mortality rates. The advent of third and fourth-generation EGFR tyrosine kinase inhibitors (TKIs) has significantly advanced the therapeutic landscape for EGFR-mutant NSCLC, particularly in overcoming resistance mutations such as T790M and C797S. This review delves into the current clinical status, efficacy, safety profiles, and regulatory approvals of third-generation EGFR TKIs, including Osimertinib, Lazertinib, Furmonertinib, Aumolertinib, Rezivertinib, Befotertinib, Sunvozertinib. Furthermore, it explores emerging fourth-generation EGFR TKIs designed to address resistance mechanisms beyond those targeted by their predecessors. Notable fourth-generation candidates such as TQB3804, BPI-361175, BDTX-1535, WJ13404, QLH11811, H002, HS-10375, BBT-207, JIN-A02, and HS-10504 are highlighted for their potential to overcome the C797S mutation. The review emphasizes the importance of these advanced inhibitors in enhancing "progression-free survival and overall survival rates". By evaluating the therapeutic potential and limitations of these EGFR TKIs, this review aims to guide future research in the management of EGFR-mutant NSCLC. This acts as guiding beacon for the strategic design and development of third and fourth generation EGFR-TK inhibitors to overcome the drug resistance hurdles in the development of EGFR-TK inhibitors.

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.

Molecular testing of lung cancer in Australia: consensus best practice recommendations from the Royal College of Pathologists of Australasia in collaboration with the Thoracic Oncology Group of Australasia

Molecular testing plays a critical role in guiding optimal treatment decisions for lung cancer patients across a variety of clinical settings. While guidelines for biomarker testing exist in other jurisdictions, to date no best practice guidelines have been developed for the Australian setting. To address this need, the Royal College of Pathologists of Australasia collaborated with the Thoracic Oncology Group of Australasia to identify state-based pathologists, oncologists and consumer representatives to develop consensus best practice recommendations. Sixteen recommendations were established encompassing appropriate biomarkers, lung cancer subtype, tumour stage, specimen types, assay selection and quality assurance protocols that can inform and standardise best practice in molecular testing of lung cancer. These multidisciplinary evidence-based recommendations are designed to standardise and enhance molecular testing practices for lung cancers and should help ensure laboratories provide high-quality molecular testing of lung cancer for all Australians, including those from regional or remote communities.

Adjuvant epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) for the treatment of people with resected stage I to III non-small-cell lung cancer and EGFR mutation

BACKGROUND

Postoperative adjuvant epidermal growth factor receptor (EGFR) inhibitor osimertinib is the standard care for stage IB-IIIB non-small-cell lung cancer (NSCLC) with EGFR exon 19 deletions or exon 21 L858R mutation, following complete tumour resection, with or without prior platinum-based adjuvant chemotherapy. However, the role of EGFR tyrosine kinase inhibitors (TKIs) in this setting is debated, particularly concerning long-term curative effects versus recurrence delay. Uncertainties persist around treatment duration, harms, and effectiveness across disease stages, prior chemotherapy, or EGFR-sensitising mutation types.

OBJECTIVES

To assess the effectiveness and harms of adjuvant EGFR tyrosine kinase inhibitors (TKIs) in people with resected stage I to III non-small-cell lung cancer (NSCLC) harbouring an activating EGFR mutation.

SEARCH METHODS

We searched major databases (CENTRAL, MEDLINE, Embase) to 9 December 2024, along with conference proceedings (from 2019) and clinical trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) reporting benefits or harms of adjuvant EGFR TKIs in adults with resected stage I-III NSCLC. Trials compared EGFR TKIs with platinum-based chemotherapy, placebo/best supportive care (BSC), or second-and/or third-generation EGFR TKIs versus first- and/or second-generation EGFR TKIs. Participants were adults with histologically confirmed stage I-III NSCLC.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed search results, resolving disagreements with a fourth author. Primary outcomes were overall survival (OS), disease-free survival (DFS), and adverse events (AEs); secondary outcomes included health-related quality of life (HRQoL), relapse risk during drug-off time, and brain relapse risk. We conducted meta-analyses using random-effects and fixed-effect models with hazard ratios (HRs) or risk ratios (RRs) and 95% confidence intervals (CIs). We assessed heterogeneity with the I² statistic.

MAIN RESULTS

We included nine RCTs involving 2603 participants, and identified six ongoing trials. Five trials compared EGFR TKIs with placebo/BSC, and four compared them with chemotherapy. We found no trials comparing second-and/or third-generation to first- and/or second-generation EGFR TKIs. Six trials had low selection bias risk; most had unclear or high risk for detection or performance bias; and four were high risk for other biases. The certainty of the evidence (GRADE) ranged from moderate to very low, depending on the outcome. First-, second-, and/or third-generation EGFR TKIs versus placebo/BSC EGFR TKIs probably improve overall survival compared to placebo/BSC (HR 0.54, 95% CI 0.40 to 0.73; 3 studies, 864 participants; moderate-certainty evidence). TKIs may improve disease-free survival compared to placebo/BSC, but the evidence is very uncertain (HR 0.34, 95% CI 0.28 to 0.41; 5 studies, 1153 participants). We are uncertain if there is a difference between groups in serious adverse events (≥ grade 3) as the evidence is very uncertain, with wide confidence intervals spanning both potential harm and no effect (RR 2.52, 95% CI 0.44 to 14.37; 4 studies, 1134 participants). Mild-to-moderate adverse events (grades 1 and 2) may be more frequent with EGFR TKIs compared to placebo/BSC, but the evidence is very uncertain (RR 1.57, 95% CI 1.08 to 2.29; 4 studies, 1134 participants). One study assessed HRQoL, with no clinically meaningful decline compared to placebo/BSC (592 participants; moderate-certainty evidence). First-, second-, and/or third-generation EGFR TKIs versus chemotherapy Overall survival was similar between EGFR TKIs and chemotherapy (HR 0.79, 95% CI 0.52 to 1.18; 4 studies, 878 participants; moderate-certainty evidence). TKIs may have improved disease-free survival compared to chemotherapy (HR 0.54, 95% CI 0.35 to 0.83; 4 studies, 878 participants; low-certainty evidence). TKIs may have reduced serious adverse events (≥ grade 3) compared to chemotherapy (RR 0.31, 95% CI 0.18 to 0.52; 4 studies, 811 participants; low-certainty evidence). TKIs may have increased mild-to-moderate adverse events (grades 1 and 2) (RR 2.13, 95% CI 1.20 to 3.78; 4 studies, 811 participants; low-certainty evidence). Two studies assessed HRQoL, showing no clear difference compared to chemotherapy, as assessed with the Functional Assessment of Cancer Therapy-Lung instrument (2 studies, 399 participants) and the Lung Cancer Symptom Scale (2 studies, 400 participants), both with moderate-certainty evidence.

AUTHORS' CONCLUSIONS

Adjuvant EGFR TKIs may improve disease-free survival compared to both placebo/BSC and chemotherapy. There is moderate-certainty evidence that EGFR TKIs increase overall survival compared to placebo/BSC. However, they likely result in little to no difference in overall survival compared to chemotherapy. We could not rule out a potential survival benefit of adjuvant chemotherapy in people with EGFR-mutant NSCLC. Approximately 50% of participants experienced relapse or death within one year of stopping TKI therapy, indicating that the disease-free survival benefit may wane after withdrawal. This raises the possibility that prolonged adjuvant TKI therapy could be associated with improved long-term outcomes, although further research is needed to clarify this.

Association between EGFR mutation types and incidence of brain metastases in postoperative patients with stage I-III NSCLC

OBJECTIVE

This retrospective study aims to clarify the association between epidermal growth factor receptor (EGFR) mutation types and brain metastasis incidence in early-stage non-small-cell lung cancer after surgery.

METHODS

Patients pathologically diagnosed with stage I to III non-small-cell lung cancer were consecutively enrolled from January 2010 to January 2017 and reviewed. First-generation TKIs were selected as postoperative therapy for those with EGFR mutations, and platinum-based chemotherapy was used as postoperative therapy for patients with negative wild-type gene mutations. A Kaplan-Meier approach was used to calculate the cumulative incidence of brain metastasis and overall survival. Candidate prognostic factors were checked by log-rank test.

RESULTS

A total of 669 patients were eligible for the study, comprising 309 who were EGFR(+), and 360 who were EGFR(-). Patients with any type of EGFR mutation have a significantly higher risk of developing brain metastases compared to those with EGFR wild-type (hazard ratio=1.957, P=0.012). The incidence of brain metastasis was 17.1% higher in patients with the 19Del mutation than in those with the L858R mutation (13.6%), other mutations (13.3%), or wild-type EGFR (6.1%). Moreover, those with 19Del mutations showed the greatest increase in incidence of brain metastasis (hazard ratio=3.009, P=0.001); those with L858R mutations showed a smaller increase (hazard ratio=2.750, P=0.003).

CONCLUSIONS

EGFR mutations are predictive factors for the cumulative incidence of brain metastasis. EGFR-mutant non-small-cell lung cancer patients may need more frequent brain magnetic resonance imaging to detect earlier occurrence of brain metastases, allowing for timely and effective treatment to improve patient prognosis.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Investigation of cardiotoxicity in patients treated with osimertinib: findings from the OSI-FACT study

INTRODUCTION

Osimertinib is a highly effective first-line treatment for advanced epithelial growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC). With its expanded perioperative use, the long-term risk of cardiotoxicity merits investigation. We assessed the occurrence and risk factors of QT prolongation and cardiac dysfunction in patients with NSCLC treated with first-line osimertinib across multiple institutions.

METHODS

This retrospective cohort study, a part of the OSI-FACT study, included 538 patients who started first-line osimertinib treatment between August 2018 and December 2019. Patients receiving concurrent anticancer therapies were excluded. Clinical data, including patient characteristics, EGFR mutation status, and tumor stage, were analyzed. Cardiotoxicity graded per Common Terminology Criteria for Adverse Events version 5.0 was monitored via ECG and echocardiography over a median follow-up of 37 months.

RESULTS

QT prolongation occurred in 23 patients (4.3 %), with eight reaching Grade ≥3. The median time to onset was 246 days. No significant risk factors for QT prolongation were identified. Cardiac dysfunction was reported in 14 patients (2.6 %), with five cases of Grade ≥3. The median onset was 171 days, with cases occurring after six months. Multivariate analysis identified poor performance status as a risk factor for cardiac dysfunction (HR 2.24, p = 0.005).

CONCLUSION

Osimertinib-related cardiotoxicity, while rare, has important clinical implications, particularly for older patients and those with comorbidities. Regular monitoring, beyond the first year, is essential to ensure patient safety.

Selpercatinib in RET Fusion-Positive Non-Small Cell Lung Cancer: Final Safety and Efficacy, Including Overall Survival, From the LIBRETTO-001 Phase I/II Trial

LIBRETTO-001 (ClinicalTrials.gov identifier: NCT03157128) is a registrational phase I/II, single-arm, open-label trial of selpercatinib in RET-dependent cancers. With 19 months of additional follow-up, we report the final efficacy and safety results of selpercatinib in patients with RET fusion-positive non-small cell lung cancer (NSCLC) who had previously received platinum-based chemotherapy (N = 247) or were treatment-naïve (N = 69). The objective response rate (ORR) was 62% for pretreated patients and 83% for treatment-naïve patients. Duration of response (DoR) was 31.6 months for pretreated and 20.3 months for treatment-naïve patients (median follow-up approximately 38 months). Median progression-free survival (PFS) was 26.2 months for pretreated and 22.0 months for treatment-naïve patients (median follow-up approximately 40 months). Median overall survival was 47.6 months in pretreated patients and was not reached in the treatment-naïve group (median follow-up approximately 43 months). At the 3-year landmark estimate, 57% of pretreated and 66% of treatment-naïve patients were alive. Among 26 patients with measurable CNS metastases at baseline, the CNS-ORR was 85% with a CNS-DoR of 9.4 months and CNS-PFS of 11.0 months. The safety profile of selpercatinib was consistent with previous reports. With substantial additional follow-up, selpercatinib continued to show durable responses and intracranial activity, with a manageable safety profile in patients with RET fusion-positive NSCLC.

New therapeutic approaches for EGFR mutated non-small cell lung cancer on osimertinib era

INTRODUCTION

EGFR-mutated non-small cell lung cancer (EGFRmut NSCLC) represents a heterogeneous group of tumors with varying clinical outcomes. Resistance to osimertinib, a third-generation EGFR tyrosine kinase inhibitor (EGFR-TKI), is inevitable, with emerging evidence suggesting that concurrent genomic alterations influence treatment efficacy.

MATERIALS AND METHODS

This retrospective study analyzed 58 stage IV EGFRmut NSCLC patients treated with osimertinib across four hospitals in Madrid, Spain, between March 2021 and February 2023. Comprehensive genomic profiling was conducted using next-generation sequencing (NGS) to evaluate co-mutations. Kaplan-Meier survival curves and Cox regression were applied to assess progression-free survival (PFS) and overall survival (OS).

RESULTS

A second co-mutation was identified in 44.1 % of patients, with TP53 (70 %) being the most frequent, followed by EGFR (11.5 %), PI3K (11.5 %), and MET amplifications (7.7 %). Patients with co-mutations exhibited significantly worse PFS compared to those with only EGFR mutations (HR: 8.0, 95 % CI: 1.81-35.4; p = 0.001). Specifically, TP53 co-mutations were associated with reduced PFS (HR: 21.6, 95 % CI: 2.77-169; p < 0.001) and a non-statistically significant trend toward worse OS (HR: 3.10, 95 % CI: 0.89-10.8; p = 0.062).

DISCUSSION

This study highlights the prognostic impact of co-mutations, particularly TP53, in EGFRmut NSCLC treated with osimertinib. These findings underscore the need for novel therapeutic approaches and personalized treatment strategies, especially in subgroups with poor prognoses. Trials such as MARIPOSA and FLAURA-2 provide promising evidence for treatment intensification, but careful patient stratification is essential to balance efficacy and toxicity.

Investigating the anticancer effect of purified rCec-B peptide in a DEN murine model: Insights into tumorigenesis prevention, bioavailability, and molecular mechanisms

BACKGROUND

Anticancer peptides (ACPs) are considered cancer therapeutic candidates through decreasing tumor cell proliferation, migration, and angiogenesis.

OBJECTIVES

Determine the therapeutic potential of purified recombinant cecropin-B (rCec-B) peptide in vivo on HCC murine model and its effect, particularly on the activation of apoptotic pathways.

METHODS

Intact mass analysis of rCec-B was confirmed using mass spectrometry, molecular docking on epidermal growth factor receptor (EGFR) apoptosis was studied, and an in vivo acute toxicity study, followed by establishing the HCC model using diethylnitrosamine (DEN) was performed. Biochemical, molecular, and immunohistochemical parameters were detected in serum and liver samples.

RESULTS

A molecular docking study on EGFR showed a predicted binding model of rCec-B as a ligand with a high binding affinity equal to -50.167 kcal/mol. The peptide showed remarkable safety in the studied high doses. The liver of the HCC untreated model had a distorted lobular pattern with minimal to mild nuclear atypia. In HCC treated with rCec-B, liver sections had periportal inflammation, hydropic degeneration with focal cholestasis, and apoptotic hepatocellular bodies. Molecular detection and immunohistochemical analysis showed an upregulation of the oncogenic marker, Bcl-2, and a downregulation of apoptotic markers (FAS, FAS-L, Cas-8, BAX, and BID) in the untreated DEN group. Treated groups had a significant increase in all the detected apoptotic markers.

CONCLUSION

This study sheds light on the potential rCec-B's role in suppressing HCC progression. Hence, this peptide could be considered a promising therapeutic drug alone or in combination with other drugs to alleviate HCC treatment.

RA16-Modified DNA Tetrahedra: Targeted Delivery and Inhibition in Non-Small Cell Lung Cancer

Lung cancer remains the leading cause of cancer-related deaths, with the five-year survival rate for non-small cell lung cancer (NSCLC) patients as low as 10%. RNA aptamer RA16 has shown potential as a targeted therapy, binding specifically to NSCLC NCI-H460 cells and inhibiting proliferation in murine models. However, its clinical application is limited by poor in vivo stability. To overcome this, we developed RA16-functionalized DNA nanomaterials, combining the aptamer's targeting ability with the stability and high drug-loading capacity of tetrahedral DNA (TD) nanostructures. In vitro assays confirmed the biocompatibility, stability, and high drug-loading capacity of RA16-TD nanoparticles. RA16-TD enhanced cell binding and internalization by 10-fold compared to free RA16. In H460 xenograft mouse models, RA16-TD accumulation at the tumor site was 2.43-fold higher than free RA16 at 72 h postadministration. Furthermore, RA16-TD-loaded Epirubicin showed superior therapeutic efficacy, with a tumor inhibition rate of 77.8%, compared to 44.6% for free Epirubicin and 51.7% for RA16-Epirubicin. These results highlight the potential of RA16-functionalized DNA nanomaterials as a promising platform for targeted therapy in NSCLC, offering avenues for clinical application.

CRISPR/Cas9 Screening Highlights PFKFB3 Gene as a Major Contributor to 5-Fluorouracil Resistance in Esophageal Cancer

BACKGROUND

Esophageal cancer (EC) is the eighth most common cancer and the sixth most common cause of death worldwide. Esophageal squamous cell carcinoma (ESCC) comprises the majority of esophageal cancers globally, and 5-Fluorouraci (5-FU) is one of the commonly used chemotherapeutics for this type of cancer. Chemoresistance to drugs is a main obstacle in the successful treatment of this malignancy.

METHODS

In this study, we used the CRISPR/Cas9 screening method to determine the target gene related to 5-FU drug resistance in esophageal cancer.

RESULTS

Our research findings indicate that the loss of PFKFB3 can increase the resistance of different human esophageal squamous cell carcinoma cell lines to 5-FU through various pathways. Specifically, in KYSE-70 cells, loss of PFKFB3 can induce epithelial-mesenchymal transition (EMT) and prolong the S phase of the cell cycle, allowing cancer cells to evade the effects of 5-FU and develop resistance. In the KYSE-270 and KYSE-150 cell lines, loss of PFKFB3 can upregulate the expression of Slug and Mcl-1, indirectly regulate Chk1 and promote its autophosphorylation, which in turn inhibits apoptosis, thus counteracting the effects of 5-FU.

CONCLUSIONS

Our research not only enriches our understanding of the biological characteristics of different ESCC cell lines but also provides new clinical insights for future personalized treatments. Assessing the status of PFKFB3 can help predict resistance to 5-FU in ESCC patients with different genetic backgrounds, allowing for more precise treatment planning. This personalized approach has the potential to improve treatment efficacy, reduce unnecessary drug use and side effects, and ultimately improve patient survival rates and quality of life.

Auranofin resensitizes ferroptosis-resistant lung cancer cells to ferroptosis inducers

Lung cancer, a major cause of cancer-related mortality, has limited therapeutic options, especially for advanced cases. Ferroptosis, an iron-dependent form of cell death, is a potential therapeutic strategy for this disease; however, resistance mechanisms in the tumor microenvironment impede its effectiveness. Therefore, in this study, we aimed to investigate the efficacy of sulfasalazine (SAS), a ferroptosis inducer, and auranofin (AUR), a Food and Drug Administration-approved anti-inflammatory agent, combination to counteract ferroptosis resistance in lung cancer. SAS induced ferroptosis in vitro; however, its efficacy in vivo was limited, possibly because of factors, such as nutrient deprivation and high cell density, in the microenvironment that suppressed the activities of Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ), key regulators of ferroptosis resistance. Screening of 2483 drugs revealed AUR as a compound resensitizing the YAP/TAZ-deficient lung cancer cells to ferroptosis. Moreover, SAS and AUR combination significantly enhanced lipid peroxidation and reactive oxygen species accumulation, further driving ferroptosis in cells. This combination effectively inhibited tumor growth and enhanced survival in a murine lung cancer model. Overall, our findings suggest that AUR potentiates ferroptosis-based therapies, serving as an effective candidate to overcome ferroptosis resistance in lung cancer.

How to report and discuss subgroup analyses in clinical practice guidelines? Evaluation procedure of the clinical and statistical relevancy

The results of subgroup analyses of clinical trials are important reference information when considering the generalizability of a study treatment, i.e., providing the best treatment for each individual patient. The results of subgroup analyses are often presented in publications, etc. as forest plots focusing on patient backgrounds. However, it is important to fully understand and grasp some of the issues involved in subgroup analyses and to interpret the results carefully to apply them in clinical practice. Although the literature includes some reports on how subgroup analyses should be evaluated and handled for the purpose of establishing medical practice guidelines, most of the papers have mainly evaluated the reliability of subgroup analyses from a statistical perspective; few of them have incorporated clinical importance in their evaluations. Therefore, in December 2019, we established a Subgroup Analysis Review Committee consisting of oncologists specializing in lung cancer treatment and statistical experts among the members of the Guidelines Review Committee of the Japanese Lung Cancer Association, with the aim of appropriately reflecting subgroup analysis in Japanese lung cancer practice guidelines. We developed a new evaluation strategy to incorporate clinical aspects as well as reliability assessment. Specifically, on the basis of a clinical and statistical review of the problems with subgroup analyses presented as clinical trial results, we developed criteria and procedures to ensure consistency and fairness in the citation of clinical guidelines.

Impact of Proton Pump Inhibitors on Osimertinib-Induced Cardiotoxicity in NSCLC Patients

There is a lack of comprehensive research investigating the relationship between proton pump inhibitors (PPIs) and osimertinib combination therapy concerning cardiotoxicity. We conducted a retrospective analysis of adverse event reports from the US Food and Drug Administration Adverse Event Reporting System (FAERS). In this analysis, we used patients with non-small cell lung cancer (NSCLC) who did not receive osimertinib or PPIs as a control group to assess the association between cardiotoxicity occurrence in patients receiving osimertinib with PPIs and those without PPIs. We employed disproportionality analysis along with both additive and multiplicative models. The reporting odds ratios (ROR) for cardiac events, including torsade de pointes/QT prolongation, cardiomyopathy, cardiac arrhythmias, cardiac failure, ischaemic heart disease, and embolic and thrombotic events, were significantly higher in patients using PPIs with osimertinib (14.11, 9.04-22.04; 4.67, 2.67-8.16; 4.43, 3.17-6.20; 3.67, 2.53-5.34; 2.24, 1.31-3.84; 1.92, 1.43-2.56, respectively) compared to osimertinib alone (4.87, 3.91-6.07; 2.50, 2.02-3.09; 1.59, 1.37-1.84; 2.00, 1.74-2.29; 0.65, 0.50-0.84; 1.01, 0.91-1.11). Our investigation unveiled an elevated risk of cardiotoxicity in NSCLC patients when osimertinib was combined with PPIs, compared to osimertinib monotherapy. Therefore, vigilant monitoring for cardiotoxicity is paramount in NSCLC patients undergoing these combined treatments.

Palliative and end-of-life care in Asian and White patients with metastatic lung cancer

BACKGROUND

Data on palliative and end-of-life care for Asian patients with metastatic lung cancer in the United States are limited, though this is the leading cause of cancer death in this group. Early palliative care improved quality of life and survival in patients with metastatic lung cancer treated with chemotherapy. We examined palliative and end-of-life care patterns in Asian and White patients with metastatic lung cancer in the era of novel therapy.

METHODS

Patients newly diagnosed with metastatic lung cancer from 2014 to 2019 were identified at our institution. Patient and disease characteristics and treatment information were compared between Asian and White patients by Mann-Whitney U test and Chi-square tests. Time-to-palliative care involvement was compared via log-rank test.

RESULTS

Both Asian (N = 89) and White (N = 197) patients had low rates of palliative care involvement (38.2% vs 37.6%), with median time from diagnosis to first encounter exceeding a year. The most given frontline systemic therapy was targeted therapy and chemotherapy in Asian and White patients, respectively. Of 22 Asian (24.7%) and 74 White (37.6%) patients who died, Asian patients more often died in-hospital (68.2% vs 32.4%, P = .004), and did not have documented code status discussions with their outpatient oncologists (0% vs 24.3%, P = .010) within 6 months preceding death.

CONCLUSION

Early palliative care appears challenging to implement for Asian and White patients newly diagnosed with metastatic lung cancer in a real-world setting. A more patient-centered approach to integrating palliative and end-of-life care communications and interventions alongside precision oncology warrants further study.

Effect of CYP3A4 inhibitor and induction on the pharmacokinetics and safety of FHND9041, a novel EGFR T790M inhibitor, in healthy Chinese

BACKGROUND

Non-small cell carcinoma is the main pathologic type of lung cancer, and a large number of clinical trials have shown that epidermal growth factor receptor tyrosinase inhibitors exhibit superior clinical efficacy and lower toxicity compared with chemotherapy. FHND9041 is a new irreversible EGFR T790M mutation-selective small molecule kinase inhibitor, a third-generation EGFR inhibitor developed by Nanjing Chuangte Pharmaceutical Technology Co., Ltd. The aim of this study was to evaluate the effects of oral Itraconazole capsules and oral Rifampicin capsules on the pharmacokinetic profile and safety and tolerability of a single oral dose of FHND9041 capsules in healthy Chinese male subjects.

PATIENTS AND METHODS

This study employed a single-center, open-label, fixed-sequence design, comprising two parallel groups: Group 1 received FHND9041 40 mg in combination with Itraconazole, while Group 2 received Rifampicin in combination with FHND9041 80 mg. Each group enrolled 16 subjects for a two-period study, with the first period involving monotherapy and the second period involving co-administration. All subjects participating in this clinical trial were healthy adult Chinese males.

RESULTS

In healthy subjects, after a single oral administration of 40 mg FHND9041 capsules, the corrected geometric mean ratios (90% confidence intervals) of FHND9041 Cmax, AUC0 - last, and AUC0 - inf when co-administered with itraconazole capsules compared to the monotherapy phase were 111.46% (103.26 - 120.30%), 169.53% (156.21 - 183.99%), and 168.25% (156.26 - 181.15%), respectively. The 90% confidence interval for Cmax fell within the 80-125% range, while the 90% confidence intervals for both AUC0 - last and AUC0 - inf exceeded the 80-125% range. Following a single oral dose of 80 mg FHND9041 capsules, the adjusted geometric mean ratios (90% confidence intervals) of Cmax, AUC0 - last, and AUC0 - inf for FHND9041 during co-administration with Rifampicin compared to monotherapy were 52.12% (41.95 - 64.74%), 16.47% (13.34 - 20.31%), and 16.51% (13.56 - 20.09%), respectively. The 90% confidence intervals for Cmax, AUC0 - last, and AUC0 - inf all fell outside the 80 - 125% range. No serious adverse events occurred during the trial.

CONCLUSIONS

Co-administration with Rifampicin significantly reduced the exposure of FHND9041. Therefore, it is recommended to avoid co-administration of FHND9041 with Rifampicin and other potent CYP3A4 inducers. Conversely, co-administration with Itraconazole significantly increased the total exposure of FHND9041. Caution is advised when FHND9041 is co-administered with Itraconazole or other strong CYP3A4 inhibitors. Close monitoring of tolerability during co-administration is essential, and dose reduction may be necessary if required. FHND9041 capsules demonstrated good safety and tolerability when used alone or in combination with strong CYP3A4 inhibitors or inducers.

TRIAL REGISTRATION

Registered 03/27/2023 ( http://www.chinadrugtrials.org.cn/index.html , CTR202300931).

Targeting exon mutations in NSCLC: clinical insights into LAG-3, TIM-3 pathways, and advances in fourth-generation EGFR-TKIs

Lung cancer remains the second leading cause of cancer-related morbidity and mortality worldwide, with non-small cell lung cancer (NSCLC) accounting for the majority of cases. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have become the standard first-line therapy for advanced NSCLC with EGFR mutations, offering significant improvements in progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) compared to chemotherapy alone. Recent studies suggest that their effectiveness decreased with the emergence of acquired resistance, such as C797S and T790M. Immunotherapy alone also shows enhanced PFS and OS over chemotherapy; however, its applicability can be limited in cases with low programmed cell death ligand 1 (PD-L1) expression and result in immune-related adverse effects like those observed in retrospective, non-randomized studies. Emerging fourth-generation EGFR-TKIs, currently under clinical trials, show promising potential to address these resistance mechanisms. Advanced inhibitors, including BBT-176, BLU-945, and BLU-701, have effectively targeted resistant mutations and reduced disease progression. Studies have suggested that combining fourth-generation EGFR-TKIs with immunotherapies targeting novel pathways like LAG-3 and TIM-3 may enhance patient outcomes. Such combination regimens aim to optimize PFS, OS, and ORR while minimizing adverse effects and addressing the limitations of current therapies. This study explores the landscape of EGFR mutations, their clinical significance, and the integration of innovative fourth-generation EGFR-TKIs with immunotherapies, emphasizing the potential of precision medicine in advancing the management of EGFR-mutated NSCLC.

Evolving treatment for advanced non-small cell lung cancer harbouring common EGFR activating mutations

A clinically important subgroup of non-small cell lung cancer (NSCLC) is driven by common mutations in the epidermal growth factor receptor (EGFR). Over the past decade, first-, second-, and third-generation EGFR tyrosine kinase inhibitors (TKIs) have substantially improved clinical outcomes, although acquired resistance inevitably emerges. In particular, the third-generation TKI osimertinib has demonstrated superior progression-free survival (PFS) and overall survival (OS) compared to earlier-generation TKIs in the frontline setting, yet median OS remains approximately three years in pivotal trials. Efforts to extend disease control have led to various upfront intensification strategies, including combining EGFR TKIs with antiangiogenics or chemotherapy (e.g., the FLAURA-2 trial), and pairing novel bispecific antibodies such as amivantamab with third-generation TKIs. Upon progression on third-generation EGFR TKIs, platinum-based chemotherapy remains the standard second-line treatment, albeit with modest response rates. Emerging therapies targeting MET amplification (e.g., savolitinib plus osimertinib), leveraging antibody-drug conjugates (e.g., patritumab deruxtecan), or adding immunotherapy and antiangiogenics have shown preliminary promise in overcoming resistance. Ongoing trials are assessing optimal treatment sequencing and the use of circulating tumor DNA (ctDNA) to guide therapy escalation or de-escalation. Ultimately, the evolving landscape of EGFR-mutant NSCLC underscores the need for refined biomarker-driven approaches and personalized regimens to achieve further gains in survival. In this review, we discuss these strategies in detail, highlighting current evidence and future directions for EGFR-mutant NSCLC treatment.

Exploiting YES1-Driven EGFR Expression Improves the Efficacy of EGFR Inhibitors

EGFR is a highly expressed driver of many cancers, yet the utility of EGFR inhibitors (EGFRi) is limited to cancers that harbor sensitizing mutations in the EGFR gene because of dose-limiting toxicities. Rather than conventionally blocking the kinase activity of EGFR, we sought to reduce its transcription as an alternative approach to broaden the therapeutic window for EGFR inhibitors targeting wild-type (WT) or mutant EGFR. We found that YES1 is highly expressed in triple-negative breast cancer (TNBC) and drives cell growth by elevating EGFR levels. Mechanistically, YES1 stimulates EGFR expression by signaling to JNK and stabilizing the AP-1 transcription factor c-Jun. This effect extends beyond TNBC as YES1 also sustains EGFR expression in non-small cell lung cancer cells, including those that harbor the EGFR gatekeeper mutation T790M. The novel ability of YES1 to regulate the expression of WT and mutant EGFR mRNA and protein provides a potential therapeutic opportunity of utilizing YES1 blockade to broadly increase the efficacy of EGFR inhibitors. Indeed, we observed synergy within in vitro and in vivo models of TNBC and non-small cell lung cancer, even in the absence of EGFR-activating mutations. Together, these data provide a rationale for blocking YES1 activity as an approach for improving the efficacy of EGFR-targeting drugs in cancers that have generally been refractory to such inhibitors. Implications: YES1 sustains EGFR expression, revealing a therapeutic vulnerability for increasing the efficacy of EGFR inhibitors by lowering the threshold for efficacy in tumors driven by the WT or mutant receptor.

A Prospective Phase II Trial of First-Line Osimertinib for Patients With EGFR Mutation-Positive NSCLC and Poor Performance Status (OPEN/TORG2040)

INTRODUCTION

Osimertinib is the first-line treatment for patients with NSCLC who have EGFR mutations and favorable performance status (PS). Despite the increasing clinical data on osimertinib, evidence for its use in patients with impaired PS remains limited. Therefore, a multicenter phase II trial (OPEN/TORG2040) was conducted to evaluate the efficacy and safety of first-line osimertinib treatment in patients with EGFR mutation-positive NSCLC and a poor PS.

METHODS

Patients with previously untreated advanced NSCLC harboring EGFR-sensitizing mutations and PS of 2 to 4 were enrolled. Osimertinib (80 mg once daily) was orally administered to eligible patients. The primary end point was objective response rate. The secondary end points were disease control rate, PS improvement rate, patient-reported outcomes, and safety.

RESULTS

Between February 2021 and February 2022, 30 patients with poor PS (22 with a PS of 2, six with a PS of 3, and two with a PS of 4) were enrolled. The median age was 75 (range, 41-92) years, and 18 patients had brain metastases. The objective response rate was 63.3% (90% confidence interval, 46.7%-77.9%; one-sided, p = 0.033). Disease control and PS improvement rates were 93.3% and 63.3%, respectively. Global health status/QoL also improved. Median progression-free and overall survival were 8.0 and 25.4 months, respectively. Eight patients (26.7%) experienced serious adverse events leading to discontinuation, and six (20.0%) experienced interstitial lung disease.

CONCLUSIONS

This prospective study confirmed the efficacy of first-line osimertinib treatment in patients with EGFR mutation-positive NSCLC and poor PS, highlighting the need for interstitial lung disease risk management.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials Identifier: jRCTs041200100.

Survival Outcomes in EGFR-Mutant Non-Small Cell Lung Cancer With Brain Metastases: Kaplan-Meier and Cox Regression Analyses Across Treatment Stages

BACKGROUND

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have shown significant efficacy in patients with brain metastases (BMs) from EGFR-mutated non-small cell lung cancer (NSCLC). However, acquired resistance is inevitable, and clinical data addressing key questions across treatment stages remain insufficient, limiting the formulation of precise treatment strategies.

METHODS

This retrospective study analyzed 302 EGFR-mutant NSCLC patients with BMs treated at Shandong Cancer Hospital (2014-2022). Patients were divided into three cohorts: cohort A (first-/second-generation EGFR-TKIs without third-generation use), cohort B (first-/second-generation followed by third-generation EGFR-TKIs), and cohort C (first-line third-generation EGFR-TKIs). Survival outcomes were evaluated using Kaplan-Meier and Cox regression analyses across three treatment stages. Propensity score matching (PSM) adjusted for baseline imbalances.

RESULTS

Third-generation EGFR-TKIs demonstrated superior progression-free survival (PFS) in first-line therapy compared to earlier-generation agents (median PFS1: 14.2 vs. 11.2 months; p = 0.0021), particularly for intracranial control (median iPFS1: 18.0 vs. 12.2 months; p = 0.0058). Patients with uncommon EGFR mutations had significantly shorter PFS on third-generation EGFR-TKIs than those with common mutations (4.4 vs. 12.9 months; p = 0.012). After resistance, combination therapy with immune checkpoint inhibitors (ICIs), antiangiogenics, and chemotherapy extended overall survival (OS) versus non-ICI regimens (median OS2: 17.3 vs. 10.4 months; p = 0.004).

CONCLUSIONS

Third-generation EGFR-TKIs are effective first-line options for BMs but show limited efficacy against uncommon mutations. Post-resistance regimens integrating ICIs, antiangiogenics, and chemotherapy may improve survival. Reassessment of genetic and PD-L1 status is critical for guiding sequential therapy.

Outcomes After Radiation for Oligoprogressive Disease Sites in Patients With EGFR-Mutant Lung Cancer Treated With Osimertinib

PURPOSE

Oligoprogressive disease (OPD) commonly occurs in patients with advanced EGFR mutation-positive non-small cell lung cancer (EGFR+ LC) on systemic therapy. While radiation therapy (XRT) to treat OPD can improve outcomes, the clinical and genomic predictors of benefit from local therapy for oligoprogression on osimertinib are unclear.

METHODS

We conducted a single-center retrospective analysis of 81 patients with EGFR+ LC on osimertinib who received XRT for OPD (defined as progression in ≤5 lesions) between January 2014 and December 2022. Progression patterns were identified. Times from local therapy to progression, next therapy, and death were measured.

RESULTS

The median duration of osimertinib treatment before XRT was 16.9 months. After XRT, time on osimertinib was extended for a median of 9.7 months, with a median progression-free survival (PFS) and overall survival of 6.9 and 24.4 months, respectively. Post-XRT recurrence was most common in the lung (43%), viscera (35%), and bone (35%), with only 15% of patients experiencing in-field recurrence. Patients receiving XRT to lymph nodes or visceral metastases exhibited shorter PFS compared with other sites. EGFR mutation type, concurrent TP53/RB1 mutations, and mechanisms of resistance did not significantly predict outcomes.

CONCLUSION

The addition of XRT for OPD led to clinically meaningful time on continued osimertinib beyond progression, irrespective of molecular characteristics or resistance mechanisms.

Impact of Modifying Lazertinib Doses on Effectiveness and Safety in Patients With EGFR-Positive Advanced Lung Cancer: A Multicenter, Prospective Observational Cohort Study

INTRODUCTION

The clinical application of lazertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, has extended to the treatment of EGFR-mutant non-small-cell lung cancer (NSCLC); however, the effects of its dose modification on its efficacy and safety have not yet been adequately established.

METHODS

This prospective, multicenter, observational cohort study aims to evaluate the clinical implications of adjusting the lazertinib dose. Patients will be categorized into two groups based on the lazertinib dose administered during the initial 12 weeks of treatment in routine clinical practice: 160 and 240 mg groups. The primary endpoints are progression-free survival in the 160 mg group and identifying risk factors associated with dose modification during the 12-week period.

DISCUSSION

The findings from the present study will provide real-world insights into the clinical factors leading to lazertinib dose adjustments and deepen our understanding of the efficacy and safety of lazertinib in patients with NSCLC. Our research will contribute toward optimizing medical strategies for NSCLC treatment and aid clinicians in making accurate clinical decisions regarding dose modifications in routine practice.

Inter-Ethnic Differences in the Efficacy and Safety of Tyrosine Kinase Inhibitors Used in Oncology: Insights From Phase 3 Clinical Trials

Differences in the efficacy and safety of tyrosine kinase inhibitors (TKIs) have been observed across ethnic/ancestry subpopulations (previously reviewed to 2017). With an expanding number of TKIs approved since that time, an updated review of TKI response across ethnic/ancestry subpopulations in Phase 3 TKI clinical trials was conducted. A total of 73 population subgroup analyses (defined by participant race, ethnicity, ancestry or geographic region) of progression-free survival (PFS) and/or overall survival (OS) were identified by a literature search. Twelve (16%) of the analyses investigating the efficacy of afatinib, brigatinib, dacomitinib, gilteritinib, lorlatinib, neratinib, osimertinib, or pazopanib were assessed to report population differences in PFS and/or OS. For 28 (38%) of the analyses that showed suggestions of a potential efficacy difference across subpopulations, limitations in the data available precluded further assessment. There were 17 (23%) analyses assessed to report comparable efficacy outcomes across diverse subpopulations. The majority of clinical trials noted no clinically remarkable differences in safety between subpopulations; however, for brigatinib, crizotinib, pazopanib, and sunitinib, distinct patterns of adverse events were reported in the Asian and non-Asian subgroups. The underrepresentation of specific subpopulations, the grouping together of results of diverse subpopulations, as well as inconsistencies in the definition and reporting of participant ethnicity/ancestry are barriers to the meaningful exploration of inter-ethnic differences in TKI response. Therefore, further insight into the associations between ethnicity/ancestry and TKI response will require an increase in the diversity of clinical trial participants and appropriate analysis and reporting of subpopulation results.

Multi-omic profiling in breast cancer: utility for advancing diagnostics and clinical care

INTRODUCTION

Breast cancer remains a major global health challenge. While advances in precision oncology have contributed to improvements in patient outcomes and provided a deeper understanding of the biological mechanisms that drive the disease, historically, research and patients' allocation to treatment have heavily relied on single-omic approaches, analyzing individual molecular dimensions such as genomics, transcriptomics, or proteomics. While these have provided deep insights into breast cancer biology, they often fail to offer a complete understanding of the disease's complex molecular landscape.

AREAS COVERED

In this review, the authors explore the recent advancements in multi-omic research in the realm of breast cancer and use clinical data to show how multi-omic integration can offer a more holistic understanding of the molecular alterations and their functional consequences underlying breast cancer.

EXPERT OPINION

The overall developments in multi-omic research and AI are expected to complement precision diagnostics through potentially refining prognostic models, and treatment selection. Overcoming challenges such as cost, data complexity, and lack of standardization is crucial for unlocking the full potential of multi-omics and AI in breast cancer patient care to enable the advancement of personalized treatments and improve patient outcomes.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Relationship Between T790M Allele Frequency and Therapeutic Effects Before and After EGFR-TKI Administration Using Droplet Digital PCR in Non-small-cell Lung Cancer With EGFR Mutation

Background/Aim

This study aimed to investigate the effectiveness of sequential treatment with afatinib and osimertinib by clarifying the correlation between therapeutic effects and EGFR T790M mutant allele frequency.

Patients and Methods

From August 2013 to July 2019, tumor samples from before and after epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) administration were collected from patients from eight institutions. We measured T790M mutant allele frequency using droplet digital polymerase chain reaction using biopsy specimens from patients mainly treated with afatinib and analyzed the T790M to EGFR-activating mutation ratio (T/A ratio) in pre- and post-biopsy tissue.

Results

Among 36 patients (afatinib group: n=24, first-generation EGFR-TKI group: n=12) with preserved pre- and post-biopsy tissue, the median T/A ratios before (pre-T/A ratio) and after EGFR-TKI administration (post-T/A ratio) in the afatinib group were 0.005 and 0.014, and those in the first-generation EGFR-TKI group were 0.026 and 0.352, respectively. The results of a Mann-Whitney U-test revealed that the difference between the pre-T/A and post-T/A ratios was not higher in the afatinib group than in the first-generation EGFR-TKI (p=0.0372). No significant difference in progression-free or overall survival was found between the two groups.

Conclusion

Compared with first-generation EGFR-TKI treatment, treatment with afatinib did not affect changes in the T/A ratio.

Central Nervous System Metastases from Primary Lung Carcinoma: Significance of RNA Fusion Testing and Early Versus Late Metastases

Background/Objectives: While the genomic landscape of primary lung carcinomas is well characterized, there is a relative scarcity of fusion data on corresponding central nervous system (CNS) metastases. This study aimed to elucidate the molecular profiles of CNS metastases to (1) assess the significance of a combined DNA-reflex RNA fusion testing approach and (2) compare the mutational landscape between patients who present initially [early (≤2 months)] with CNS metastases and those who develop CNS metastases thereafter [late (>2 months)]. Methods: We performed a retrospective search of CNS metastases of adenocarcinoma of probable lung origin interrogated by targeted DNA-reflex RNA next-generation sequencing (NGS). The DNA NGS panel included the driver mutations EGFR, BRAF, KRAS, MET, and ERBB2. RNA NGS included ALK, RET, ROS1, and MET. Additionally, mutational profiles were examined between those with early versus late CNS metastases. Results: Of the 58 patients, 44 (75.9%) had mutations or alterations, including 34 identified by DNA NGS [EGFR (n = 17; 50.0%), KRAS (n = 15; 44.1%), MET (n = 2; 5.9%)] and 10/24 by RNA NGS [ALK (n = 7; 70%), MET (n = 2; 20%), ROS1 (n = 1; 10%)]. Of all patients, 32 (55%) presented with early and 26 (45%) with late CNS metastases. Although patients with early metastases had worse survival compared to those with late metastases (p < 0.001), there were no statistically significant differences in the mutational profiles between the two cohorts. Conclusions: A significant proportion of CNS metastases without driver mutations identified by DNA NGS had targetable alterations identified by RNA NGS (10/24, 41.7%). In summary, a combined DNA with reflex RNA fusion testing approach plays a significant role in detecting and potentially managing CNS metastases. Comprehensive prospective studies are essential to elucidate the differences between early and late CNS metastases.

Adjustment of Conditional Bias in Hazard Ratios for Group Sequential Testing of Progression-Free Survival and Overall Survival

In confirmatory randomized controlled trials of patients with metastatic cancer, progression-free survival (PFS) and overall survival (OS) are often used as multiple primary endpoints. The overall hierarchical strategy is a typical multiplicity adjustment method that analyzes PFS once and performs an interim OS analysis at the time of PFS analysis using an alpha-spending function-only if the statistical significance of PFS is demonstrated. A subsequent final OS analysis is conducted if the interim OS analysis does not result in early stopping for efficacy. In this study, we focused on the adjustment of conditional bias (CB) in hazard ratio estimates for OS in both interim and final analyses when a trial applied the overall hierarchical strategy. As CB-adjusting estimators for a single primary endpoint may have limited performance, we extended the conditional mean-adjusted estimator to the case of an overall hierarchical strategy. Motivated by an actual oncology trial, we evaluated the performance of the proposed estimators through a simulation study. In the case of early stopping for efficacy, the CB of the proposed estimator was smaller than that of the existing methods with comparable root mean squared error.

Strategies Beyond 3rd EGFR-TKI Acquired Resistance: Opportunities and Challenges

The seminal identification of epidermal growth factor receptor (EGFR) mutations as pivotal oncogenic drivers in non-small cell lung cancer (NSCLC) has catalyzed the evolution of biomarker-guided therapeutic paradigms for advanced disease. Currently, third-generation EGFR tyrosine kinase inhibitors (EGFR-TKI) have revolutionized first-line treatment for advanced EGFR-mutated NSCLC, yet acquired resistance remains an inevitable and formidable clinical challenge. This review systematically summarizes molecular mechanisms underlying treatment resistance, with a focus on clinical challenges associated with central nervous system (CNS) metastases. Therapeutic resistance mechanisms are categorized into EGFR-dependent (on-target) pathways, typified by acquired kinase domain mutations (e.g., C797S), and EGFR-independent (off-target) pathways, involving compensatory activation of parallel signaling effectors (e.g., MET amplification, HER2 activation) or phenotypic transformation. We further evaluated contemporary diagnostic modalities for identifying resistance drivers and appraised emerging therapeutic strategies, including fourth-generation EGFR-TKI, various combination therapies, and antibody-drug conjugates (ADCs), and so forth, with emphasis on ongoing clinical trials that may transform the existing treatment paradigm. By synthesizing preclinical and clinical insights, this review aims to advance mechanistic understanding and propose therapeutic strategies to overcome acquired resistance to third-generation EGFR-TKI in first-line treatment.

Renal dysfunction during osimertinib treatment in patients with non-small cell lung cancer positive for EGFR mutations

BACKGROUND

Osimertinib is a standard treatment for non-small cell lung cancer (NSCLC) positive for EGFR activating mutations. Although renal dysfunction associated with osimertinib treatment is reported to be rare, detailed information on this adverse effect is needed because cytotoxic drugs such as pemetrexed are also widely administered for NSCLC but cannot be used in individuals with renal dysfunction.

METHODS

We retrospectively collected clinical data including the serum creatinine concentration and estimated glomerular filtration rate (eGFR) during osimertinib treatment for 130 NSCLC patients.

RESULTS

Serum creatinine and eGFR worsened gradually during osimertinib treatment, with the median value of creatinine at the point of greatest deterioration differing significantly from that at baseline (0.93 versus 0.72 mg/dL, P < 0.01). Seventy patients (54 %) experienced worsening of the CTCAE grade for creatinine increased, with the frequency of patients with grade 1 or 2 being increased significantly (P < 0.01) at the point of greatest deterioration relative to baseline (grade 1, 46.9 % versus 14.6 %; grade 2, 14.6 % versus 0.8 %, respectively). A higher serum creatinine level at baseline was a significant risk factor for worsening of the CTCAE grade (odds ratio of 1.66, P < 0.001). The median serum creatinine and eGFR at 4 weeks after osimertinib discontinuation had improved to levels similar to those for baseline.

CONCLUSIONS

Renal dysfunction occurred frequently during osimertinib treatment but was ameliorated after drug discontinuation, suggesting that, although renal function should be carefully monitored, its impairment is not likely to affect subsequent chemotherapy in most patients.

Amivantamab Plus Lazertinib in Patients With EGFR-Mutant NSCLC After Progression on Osimertinib and Platinum-Based Chemotherapy: Results From CHRYSALIS-2 Cohort A

INTRODUCTION

Treatment options for patients with EGFR-mutated NSCLC with disease progression on or after osimertinib and platinum-based chemotherapy are limited.

METHODS

CHRYSALIS-2 cohort A evaluated amivantamab plus lazertinib in patients with EGFR exon 19 deletion- or L858R-mutated NSCLC with disease progression on or after osimertinib and platinum-based chemotherapy. Primary end point was investigator-assessed objective response rate (ORR). The patients received 1050 mg of intravenous amivantamab (1400 mg if ≥ 80 kg) plus 240 mg of oral lazertinib.

RESULTS

In cohort A (N = 162), the investigator-assessed ORR was 28% (95% confidence interval [CI]: 22-36). The blinded independent central review-assessed ORR was 35% (95% CI: 27-42), with a median duration of response of 8.3 months (95% CI: 6.7-10.9) and a clinical benefit rate of 58% (95% CI: 50-66). At a median follow-up of 12 months, 32 of 56 responders (57%) achieved a duration of response of more than or equal to 6 months. Median progression-free survival by blinded independent central review was 4.5 months (95% CI: 4.1-5.8); median overall survival was 14.8 months (95% CI: 12.2-18.0). Preliminary evidence of central nervous system antitumor activity was reported in seven patients with baseline brain lesions and no previous brain radiation or surgery. Exploratory biomarker analyses using next-generation sequencing of circulating tumor DNA revealed responses in patients with and without EGFR- or MET-dependent resistance. The most frequent adverse events were rash (grouped term; 81%), infusion-related reaction (68%), and paronychia (52%). The most common grade greater than or equal to 3 treatment-related adverse events were rash (grouped term; 10%), infusion-related reaction (9%), and hypoalbuminemia (6%).

CONCLUSIONS

For patients with limited treatment options, amivantamab plus lazertinib demonstrated an antitumor activity with a safety profile characterized by EGFR- or MET-related adverse events, which were generally manageable.

Osimertinib vs. Afatinib in 1L therapy of atypical EGFR-mutated metastatic non-small cell lung cancer (mNSCLC): A multi-institution, real-world survival analysis

BACKGROUND

Data are limited on the efficacy of different TKIs for patients with atypical EGFR-mutated (AM) mNSCLC, a heterogeneous group excluding classical mutations (CM) L858R and exon19del. In our previous single-institution analysis, AM patients had longer survival with osimertinib than afatinib, but outcomes for patients with specific mutations could not be compared due to sample size.

METHODS

We performed a multi-institution, retrospective survival analysis of atypical EGFR mutated (AM) mNSCLC patients treated with 1L osimertinib or afatinib between 2015-2021 at 12 US institutions. Time to discontinuation (TTD) and overall survival (OS) were estimated using Kaplan-Meier curves and compared using log rank tests between treatment or mutation groups.

RESULTS

Among 52 patients identified, 32 (62 %) were treated with osimertinib and 20 (38 %) with afatinib. 20 had mutations in G719X (38 %), 12 in L861Q (23 %), and 5 in S768I (10 %). 34(65 %) had compound mutations: 20(62 %) had AM + CM, and 14(38 %) had ≥ 2 AMs. Among G719X (n = 20), afatinib was associated with longer time to discontinuation (TTD) (log-rank: p = 0.047) and longer OS (p = 0.043) vs. osimertinib. Median TTD (mTTD) was 20.3 m[95 %CI 7.3-24.2] and 9.4[1.7-14.0], respectively. For L861Q (n = 12), osimertinib was associated with longer TTD vs. afatinib (p = 0.004), with no statistical difference in OS (p = 0.215). mTTD was 7.2 m[2.2-12.3] and 1.3[0-3.1], respectively. In AM + CM (n = 20), osimertinib was associated with longer TTD and OS compared to those receiving afatinib (p = 0.037, p = 0.042, respectively).

CONCLUSIONS

Patients with G719X alterations experienced longer TTD and OS with afatinib than osimertinib. In contrast, patients with L861Q alterations had longer TTD with osimertinib. In AM + CM pts, TTD and OS with osimertinib were longer than afatinib, suggesting that classical mutations may be driving the outcomes. Atypical EGFR mutations may warrant distinct treatment recommendations based on the specific mutation(s) identified, but more studies are needed.

Prognostic Analysis of Pathological Stage I Lung Adenocarcinoma Harboring Major EGFR Mutations

BACKGROUND

While Epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma (LUAD) has favorable outcomes with targeted therapy, early-stage prognosis remains influenced by pathological factors and central nervous system (CNS) recurrence. The study aimed to clarify prognostic factors in pathological stage (pStage) I EGFR mutation-positive LUAD.

METHODS

Between 2015 and 2018, 2,191 pStage I LUAD cases with known EGFR status (excluding EGFR testing after recurrence) who received anatomical resection were included from multiple institutions in Japan. Univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed.

RESULTS

1,073 (49.0%) cases harbored EGFR mutations, including 419 (19.1%) with 19del and 529 (24.1%) with L858R. In cases with major EGFR mutation (n = 948), multivariate analysis showed that the absence of noninvasive area (NIA) (hazard ratio [HR]: 1.778, 95% confidence interval [CI]: 1.174-2.692, P = .0065), pStage (IA2 vs. IA1, HR: 2.079, 95% CI: 1.129-3.827, P = .0345; IA3 vs. IA1, HR: 4.009, 95% CI: 2.088-7.696, P = .0001; IB vs. IA1, HR: 5.280, 95% CI: 2.871-9.709, P < .0001), and presence of lymphatic invasion (HR: 1.855, 95% CI: 1.103-3.119, P = .0197) were independent predictors of shorter DFS, and only advanced pStage was an independent predictor of CNS recurrence (relative risk for pStage IA3 or more: 9.729, P < .0001).

CONCLUSION

In EGFR mutation-positive pStage I LUAD, those without NIA, with higher pStage and lymphatic invasion were independent predictive factors for DFS, and pStage ≥ IA3 was an independent predictor of CNS recurrence.

Predicting Gene Comutation of EGFR and TP53 by Radiomics and Deep Learning in Patients With Lung Adenocarcinomas

PURPOSE

This study was designed to construct progressive binary classification models based on radiomics and deep learning to predict the presence of epidermal growth factor receptor ( EGFR ) and TP53 mutations and to assess the models' capacities to identify patients who are suitable for TKI-targeted therapy and those with poor prognoses.

MATERIALS AND METHODS

A total of 267 patients with lung adenocarcinomas who underwent genetic testing and noncontrast chest computed tomography from our hospital were retrospectively included. Clinical information and imaging characteristics were gathered, and high-throughput feature acquisition on all defined regions of interest (ROIs) was carried out. We selected features and constructed clinical models, radiomics models, deep learning models, and ensemble models to predict EGFR status with all patients and TP53 status with EGFR-positive patients, respectively. The validity and reliability of each model were expressed as the area under the curve (AUC), sensitivity, specificity, accuracy, precision, and F1 score.

RESULTS

We constructed 7 kinds of models for 2 different dichotomies, namely, the clinical model, the radiomics model, the DL model, the rad-clin model, the DL-clin model, the DL-rad model, and the DL-rad-clin model. For EGFR - and EGFR +, the DL-rad-clin model got the highest AUC value of 0.783 (95% CI: 0.677-0.889), followed by the rad-clin model, the DL-clin model, and the DL-rad model. In the group with an EGFR mutation, for TP53 - and TP53 +, the rad-clin model got the highest AUC value of 0.811 (95% CI: 0.651-0.972), followed by the DL-rad-clin model and the DL-rad model.

CONCLUSION

Our progressive binary classification models based on radiomics and deep learning may provide a good reference and complement for the clinical identification of TKI responders and those with poor prognoses.

Review of Plasma Exosomal DNA for Detecting EGFR Mutations in Non-Small Cell Lung Cancer (NSCLC)

This review systematically evaluated the literature on detecting epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC) using plasma exosomal DNA by analyzing data from eight studies selected from a comprehensive literature search (PubMed, Embase, Web of Science; 2010-2024). The findings revealed a wide range of EGFR mutation prevalence (10%-26.8%) across studies, with most mutations located in exons 19 and 21. Comparative analysis highlighted the potential of plasma exosomal DNA (exDNA) as a non-invasive alternative to tissue biopsy, although significant heterogeneity in sensitivity and specificity was observed across liquid biopsy methods (including circulating tumor cells and exDNA analyses). This heterogeneity underscores the need for standardization and further validation to optimize the clinical utility of plasma exDNA in detecting EGFR mutations, monitoring treatment response, and identifying resistance mechanisms in NSCLC.

Comprehensive molecular profiling of advanced NSCLC using NGS: Prevalence of druggable mutations and clinical trial opportunities in the ATLAS study

BACKGROUND

In Spain, next-generation sequencing (NGS) is currently available in a limited number of specialized centers and remains inaccessible to a significant proportion of patients. The ATLAS study aims to explore the tumor molecular profile beyond known EGFR mutations and ALK translocations using NGS on tumor biopsy samples.

METHODS

Patients with EGFR-sensitizing mutations or ALK translocations were excluded. A total of 455 patients with advanced non-small cell lung cancer (NSCLC) were enrolled from 22 Spanish hospitals. DNA and RNA were extracted from formalin-fixed paraffin-embedded samples, and libraries were prepared using the Oncomine Focus Assay. The Trialing app was used to identify active clinical trials in Spain.

RESULTS

Mutations were detected in 65.7 % of the cases. Local pathology assessments detected druggable mutations in only 7.9 % of cases, while centralized NGS testing increased this detection rate to 25.9 %. The most prevalent druggable alteration was KRAS G12C (53.6 %), followed by MET amplification (8.1 %) and MET exon 14 skipping (7.3 %). Additionally, 34.5 % of patients had molecular alterations matching clinical trials, offering potential treatment opportunities. Women had a significantly higher probability of harbouring druggable mutations (36 % vs. 20.3 %, p < 0.001), including the KRAS G12C which was significantly more frequent in females (22.6 % vs. 10 %). KRAS mutations were more common in adenocarcinomas and increased with tumor differentiation grade (p < 0.001 and p = 0.049, respectively). Likewise, ALK translocations, EGFR mutations, BRAF V600E, MET exon 14 skipping, and RET/ROS1 fusions were mainly found in adenocarcinomas whereas copy number variations were more frequent in squamous carcinomas (28.6 % vs. 15.1 %; p = 0.003) and in men (22 % vs. 11.6 %; p = 0.008).

CONCLUSION

The ATLAS study demonstrates the utility of comprehensive NGS testing, which detects clinically relevant mutations in more than one-third of patients and may extend therapy options.

Long non-coding RNA LRTOR drives osimertinib resistance in non-small cell lung cancer by boosting YAP positive feedback loop

The therapeutic efficacy of osimertinib (OSI) in EGFR-mutant lung cancer is ultimately limited by the onset of acquired resistance, of which the mechanisms remain poorly understood. Here, we identify a novel long non-coding RNA, LRTOR, as a key driver of OSI resistance in non-small cell lung cancer (NSCLC). Clinical data indicate that elevated LRTOR expression correlates with poor prognosis in OSI-resistant patients. Functionally, LRTOR promotes tumor growth and confers OSI resistance both in vitro and in vivo. Mechanistically, LRTOR shields YAP from LATS-mediated phosphorylation at Ser127 and Ser381, preventing its proteasomal degradation. Furthermore, LRTOR facilitates the interaction between YAP and KCMF1, promoting K63-linked ubiquitination, nuclear translocation of YAP, and formation of the YAP/TEAD1 transcriptional complex, which in turn triggers the transcription of LRTOR, establishing a positive feedback loop that amplifies oncogenic signaling of YAP and consequently induces OSI resistance. LRTOR depletion by siRNA restores OSI sensitivity in resistant tumors, as demonstrated in patient-derived organoid xenograft models. Our findings unveil LRTOR as a central regulator of OSI resistance in NSCLC and propose it as a promising therapeutic and prognostic target for overcoming acquired OSI resistance in EGFR-mutant lung cancer.

Distinct Role of TP53 Co-mutations in Different EGFR Subtypes Mediating the Response to EGFR Tyrosine Kinase Inhibitors in Non-Small Cell Lung Cancer

BACKGROUND

TP53 co-mutations are closely associated with poor outcomes in patients with EGFR-mutant non-small cell lung cancer (NSCLC). Our study aimed to explore whether TP53 co-mutations affect survival and response to EGFR tyrosine kinase inhibitors (TKIs) in patients with different EGFR subtypes.

PATIENTS AND METHODS

We retrospectively analyzed 240 NSCLC with EGFR mutation (MT) from the First Affiliated Hospital of Sun Yat-sen University. The effects of TP53 co-mutations on the response to EGFR TKIs were evaluated in EGFR-mutant patients.

RESULTS

Among various EGFR-mutant subtypes, patients with EGFRL858R/TP53MT exhibited significantly worse progression-free survival (PFS) than those without TP53 co-mutations (7.9 months vs. 19.8 months, HR = 1.53, 95% CI: 1.03-2.28, P = .032), whereas a similar trend did not reappear in subgroups of EGFR19del (P = .730) and EGFRothers (P = .495). Specifically, patients with EGFRL858R/TP53MT who were treated with second-generation TKIs exhibited worse PFS than those without TP53 co-mutations. TP53 co-mutations were identified as the only independent risk factor for PFS by multivariate analysis. Moreover, TP53 co-mutations mediated the acquisition of resistance in patients harboring EGFRL858R, and concomitant mutations in additional tumor suppressor genes (TSGs) (RB1, NF1, ARID1A, and BRCA1) represented a subgroup characterized by an aggressive disease phenotype with worse PFS.

CONCLUSION

TP53 co-mutations are associated with poor survival and may cooperate with other genomic events to facilitate resistance in NSCLC harboring EGFRL858R. Sequential therapeutic interventions beyond EGFR-TKIs monotherapy may extend the survival of patients with EGFRL858R/TP53MT.

Comprehensive PTM profiling with SCASP-PTM uncovers mechanisms of p62 degradation and ALDOA-mediated tumor progression

Multiple post-translational modification (PTM) proteomics typically combines PTM enrichment with multiplex isobaric labeling and peptide fractionation. However, effective methods for sequentially enriching multiple PTMs from a single sample for data-independent acquisition mass spectrometry (DIA-MS) remain lacking. We present SDS-cyclodextrin-assisted sample preparation (SCASP)-PTM, an approach that enables desalting-free enrichment of diverse PTMs, including phosphopeptides, ubiquitinated peptides, acetylated peptides, glycopeptides, and biotinylated peptides. SCASP-PTM uses SDS for protein denaturation, which is sequestered by cyclodextrins before trypsin digestion, facilitating sequential PTM enrichment without additional purification steps. Combined with DIA-MS, SCASP-PTM quantifies the proteome, ubiquitinome, phosphoproteome, and glycoproteome in HeLa-S3 cell samples, identifying serine 28 phosphorylation as a key driver of poly(I:C)-induced p62 degradation. This method also quantifies PTMs in clinical tissue samples, revealing the critical role of ALDOA K330 ubiquitination/acetylation in tumor progression. SCASP-PTM offers a streamlined workflow for comprehensive PTM analysis in both basic research and clinical applications.

EGFR mutation testing across the osimertinib clinical program

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION NUMBERS

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

MET tyrosine kinase inhibitors in combination with EGFR tyrosine kinase inhibitors in NSCLC patients with EGFR mutations and acquired MET alterations: a systematic review and meta-analysis

BACKGROUND

Acquired MET alterations is one of the resistance mechanisms to advanced NSCLC patients treated with EGFR tyrosine kinase inhibitors (TKIs). Several clinical trials combined MET-TKI (such as capmatinib, tepotinib, savolitinib) with EGFR-TKI to overcome MET alterations resistance. We performed this meta-analysis to determine the efficacy and safety of MET-TKI plus EGFR-TKI combined therapy in NSCLC patients.

METHODS

Pubmed, Embase and the Cochrane Library were searched for relevant studies up to August 19, 2024. Data of objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), median duration of response (mDOR) and adverse events were extracted from the publications and analyzed.

RESULTS

Six studies involving 562 patients were included in this meta-analysis. Our study showed a pooled ORR of 49.2% (95% confidence interval [CI] 0.402-0.582), a pooled DCR of 78.6% (95%CI 0.680-0.893), a mDOR of 6.85 months (95%CI 5.85-7.86), and a mPFS of 5.62 months (95%CI 4.74-6.50) in MET-TKI plus EGFR-TKI combination therapy for NSCLC patients with acquired MET-driven resistance after EGFR-TKI treatment. The pooled efficacy data suggested that combining MET-TKI with a third-generation EGFR-TKI was numerically superior to combining MET-TKI with a first-generation EGFR-TKI in patients who were T790M negative with MET-dependent resistance mechanism (ORR: 56.8% vs. 47.8%, p = 0.15; DCR: 81.6% vs. 75%, p = 0.57; mDOR: 9.08 vs. 7.00 months, p = 0.25; mPFS: 7.45 vs. 4.55 months, p = 0.05). The efficacy data of capmatinib plus EGFR-TKI, savolitinib plus EGFR-TKI and tepotinib plus EGFR-TKI (regardless of generation of EGFR-TKIs) was similar (ORR:47.7% vs. 50.7% vs. 48.8%, p = 0.96; DCR: 71.4% vs. 84.9% vs. 63.3%, p = 0.02; mDOR: NR vs. 8.4 vs. 8.01 months, p = 0.18; mPFS: 5.49 vs. 6.88 vs. 5.48 months, p = 0.56). Capmatinib subgroup seemed to demonstrate lower hepatotoxicity compared with savolitinib and tepotinib subgroups numerically (increased AST level: 12.8% vs. 18.8% vs. 17.4%, p = 0.66; increased ALT level: 14.2% vs. 17.6% vs. 20.1%, p = 0.91). And a lower occurrence rate of ≥ 3 grade TRAEs was observed in the capmatinib subgroup compared to the savolitinib or tepotinib subgroups (30.0% vs. 46.7% vs. 41.2%, p = 0.07).

CONCLUSION

The findings from this meta-analysis suggest that the combination of MET-TKI and EGFR-TKI represents a promising therapeutic approach for NSCLC patients who have acquired MET alterations following EGFR-TKI treatment. Notably, the combination of MET-TKI and a third-generation EGFR-TKI demonstrated enhanced survival benefits compared to the combination with a first-generation EGFR-TKI. Furthermore, different MET-TKIs based combination therapy did not display significant differences in efficacy, while capmatinib based combination therapy showed better safety profile and lower hepatotoxicity.

Induction of IL6/STAT3-dependent TRAIL expression that contributes to the therapeutic efficacy of osimertinib in EGFR mutant NSCLC cells

The third-generation mutation-selective EGFR tyrosine kinase inhibitor (EGFR-TKI) osimertinib (or AZD9291) effectively induces apoptosis in EGFR mutant (EGFRm) non-small cell lung cancer (NCSLC) cells. However, the underlying mechanisms have not been fully elucidated. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL or TNFSF10) is known as a death ligand that initiates apoptosis via binding to its cell surface death receptors such as DR5. In this study, we found that osimertinib and other EGFR-TKIs increased the expression of TRAIL primarily in EGFRm NSCLC cell lines. This effect was accompanied with increased IL6 expression and STAT3 activation. Inhibition of STAT3 with either protein degradation or gene knockout abrogated the ability of osimertinib or recombinant human IL6 to elevate TRAIL levels. Moreover, osimertinib increased STAT3-dependent transcription of TRAIL via two STAT3 novel binding sites present in the TRAIL 5'flanking region. Hence, osimertinib induces IL6/STAT3-mediated TRAIL expression in EGFRm NSCLC cells. While osimertinib lost the ability to induce TRAIL expression in osimertinib-resistant EGFRm NSCLC, knockdown or knockout of TRAIL in sensitive EGFRm NSCLC cells rendered them less sensitive to osimertinib both in vitro and in vivo. Thus, TRAIL elevation contributes to the induction of apoptosis by osimertinib in EGFRm NSCLC cells. Furthermore, osimertinib increased membrane-bound TRAIL and DR5 membrane clustering and DR5 knockdown significantly compromised the cell-killing effect of osimertinib, together suggesting a DR5-dependent effect. Collectively, this study has revealed a previously undiscovered connection between TRAIL induction and osimertinib-induced apoptosis in EGFRm NSCLC cells, increasing our understanding of mechanisms accounting for apoptosis induced by osimertinib.