Hypoxia is linked to acquired resistance to immune checkpoint inhibitors in lung cancer

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.

Prognostic Significance of Modified Shine and Lal Index in Patients with Non-Small Cell Lung Cancer Undergoing Surgical Resection

Background: Although white blood cell-related indices are established prognostic markers in lung cancer, the prognostic significance of red blood cell (RBC) indices-mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC)-remains unclear. This study assessed the prognostic value of RBC indices for predicting survival outcomes in patients who underwent curative-intent surgery for stage I-IIIA non-small cell lung cancer (NSCLC). Methods: This retrospective analysis of 437 patients evaluated the prognostic significance of MCV, MCH, MCHC, and the modified Shine and Lal Index (mSLI), calculated as (MCV2 × MCH) × 0.0001, using Cox regression analysis. Model performance was evaluated using various metrics, including the concordance index (C-index) and integrated discrimination improvement (IDI). Results: In the multivariate Cox regression analysis, each RBC index was tested separately as an overall survival (OS) predictor in models that consistently included age, American Society of Anesthesiologists Physical Status (ASA-PS), pleural invasion, tumor-node-metastasis (TNM) stage, and the Noble and Underwood (NUn) score. Given its superior predictive performance, the mSLI model, which incorporates mSLI in addition to other covariates, was finalized and outperformed the baseline TNM staging model (C-index: 0.840 vs. 0.708, p < 0.001) and demonstrated significant improvements in IDI at 3 and 5 years (p < 0.001). Compared to the intermediate model-comprising the same covariates as the mSLI model except for mSLI-the mSLI model showed a slightly higher C-index (0.840 vs. 0.835, p = 0.554) and significant improvements in IDI at 3 years (p = 0.008) and 5 years (p = 0.020). Conclusions: mSLI was an independent prognostic marker for OS in stage I-IIIA NSCLC, enhancing risk stratification and providing incremental predictive value beyond that of traditional models. Incorporating mSLI into prognostic frameworks may improve clinical decision-making. However, external validation is required to confirm its clinical utility.

Breathing down resistance: Tackling hypoxia to overcome immunotherapy barriers in lung cancer

In this issue of JEM, Robles-Oteiza et al. (https://doi.org/10.1084/jem.20231106) present compelling evidence linking tumor hypoxia to acquired resistance mechanisms in non-small cell lung cancer (NSCLC) treatments involving immune checkpoint inhibitors (ICIs). Their research advocates targeting these hypoxic tumor regions with hypoxia-activated pro-drugs like TH-302, which may substantially delay the onset of resistance and herald a significant advancement in cancer therapy.