Expert consensus on neoadjuvant immunotherapy for non-small cell lung cancer

Analysis of the safety and feasibility of sleeve resection under UniVATS after neoadjuvant chemotherapy combined with immunotherapy for locally advanced central-type non-small cell lung cancer

OBJECTIVE

To investigate the safety and feasibility of sleeve resection under Uni-VATS following neoadjuvant chemotherapy combined with immunotherapy for locally advanced central-type non-small cell lung cancer(NSCLC).

METHODS

We analyzed 10 cIIB-IIIB NSCLC patients who underwent sleeve lung resection under single-port thoracoscopy from December 2022 to August 2023 after receiving platinum-based chemotherapy combined with albumin paclitaxel and programmed cell death protein-1 (PD-1) inhibitor drugs. Perioperative clinical data, side effects during neoadjuvant therapy, operation time, intraoperative blood loss, conversion rate to open thoracotomy, postoperative duration of chest tube placement, postoperative drainage volume, postoperative complications, and tumor outcomes were recorded.

RESULTS

This study included 10 patients. The preoperative clinical staging distribution was as follows: Stage IIB, 1 case; Stage IIIA, 5 cases; and Stage IIIB, 4 cases. Imaging evaluation after neoadjuvant therapy revealed that none of the patients achieved complete remission, whereas partial remission and stable disease were observed in 7 cases and 3 cases, respectively. All patients successfully underwent surgery, of which 2 patients required conversion to open thoracotomy (conversion rate, 20%) and 8 patients underwent single-port thoracoscopic minimally invasive surgery. Notably, 2 patients underwent sleeve resection of the right upper lobe, 2 patients underwent sleeve resection of the right middle and lower lobes, 2 patients underwent sleeve resection of the left upper lobe, and 4 patients underwent sleeve resection of the left lower lobe. The average operation time was 236 ± 87.7 min, the average intraoperative blood loss was 168 ± 62.5 mL, the average duration of chest tube placement was 5 days, the average total drainage volume was 1012 ± 464 mL, and the average hospitalization duration was 7 days. One patient developed encapsulated pleural effusion after surgery and underwent computed tomography (CT)-guided puncture drainage. At the 3-month and 6-month follow-up visits, no patient reported any particular discomfort, and chest radiography and CT revealed no abnormalities or signs of tumor recurrence.

CONCLUSION

Sleeve resection after neoadjuvant chemotherapy combined with immunotherapy for locally advanced central-type NSCLC under single-port thoracoscopy is safe and feasible and provides short-term postoperative benefits for patients.

Neoadjuvant cabozantinib for locally advanced nonmetastatic clear cell renal cell carcinoma: a phase 2 trial

Cabozantinib is an oral multikinase inhibitor approved for treatment in metastatic renal cell carcinoma (RCC). We conducted a phase 2, nonrandomized, single-arm clinical trial (NCT04022343) of cabozantinib treatment for 12 weeks in 17 patients with locally advanced, biopsy-proven, nonmetastatic clear cell RCC before surgical resection. The primary end point was the objective response rate (complete and partial responses) at week 12 and secondary end points included safety, tolerability, clinical and surgical outcomes, and quality of life. Six patients (35%) experienced a partial response and 11 patients (65%) had stable disease. The most common adverse events were diarrhea (n = 12, 70.6%), anorexia, fatigue and hypertension (n = 10, 58.8%), nausea and palmar-plantar erythrodysesthesia syndrome (n = 9, 52.9%). No treatment grade 4 or 5 adverse events related to cabozantinib or surgery occurred. The 1-year disease-free survival and overall survival were 82.4% (95% CI 54.7-93.9%) and 94.1% (95% CI 65-99.1%), respectively. Cabozantinib treatment activated CD8+ T cells in the blood, depleted myeloid populations and induced immune niches for TCF1+ stem-like CD8+ T cells. Cabozantinib was clinically active and safe in the neoadjuvant setting in patients with locally advanced nonmetastatic clear cell RCC.

Surgery/non-surgery-based strategies for invasive locally-advanced non-small cell lung cancer in the era of precision medicine

BACKGROUND

Treatments for invasive T4 non-small cell lung cancer (NSCLC) tumors have been traditionally individualized and often require multidisciplinary team (MDT) evaluation. Advances in precision medicine may open up new opportunities for these patients.

METHODS

This retrospective cohort study, using the Surveillance, Epidemiology, and End Results (SEER) database, identified T4N0-3M0 NSCLC patients with central structure invasion from 2010 to 2020. Precision medicine has progressed in three periods: 2010-2014 (targeted therapy), 2015-2017 (initial immunotherapy), and 2018-2020 (latest immunotherapy). We utilized Propensity Score Matching (PSM) to control confounding factors and competing risk regression models to evaluate cancer-specific survival (CSS).

RESULTS

A total of 9,106 cases were matched after PSM. For all populations, the median overall survival (OS) significantly increased with the advancement of precision medicine: 23.0 months in Period I (95 ​% CI: 22.0-25.0), 28.0 months in Period II (95 ​% CI: 26.0-31.0), and not reached (NR) in Period III (95 ​% CI: 30.0 - NR). Multivariate analysis also revealed a sequential survival improvement from Period I to III (p ​< ​0.001). Surgery-based treatment yielded the longest median OS at 46.0 months (95 ​% CI: 43.0-49.0, p ​< ​0.001), compared with chemoradiotherapy, chemotherapy alone and radiation alone. Surgery-based treatment has also yielded the best survival in three precision medicine eras, in both N0-1 and N2-3 categories. After analyzing CSS, the results above remained consistent. The survival following chemoradiotherapy and chemotherapy alone has seen significant and progressive enhancements across the three eras of precision medicine. There were no significant survival differences between Periods I and II among surgery-based patients, but a slight improvement trend was noted in Period III.

CONCLUSION

This retrospective study indicated that as precision medicine for NSCLC evolved, personalized treatment strategies supported by effective MDT led to survival improvement. Notably, for invasive stage III patients, surgery-based strategies have consistently shown substantial benefits across all the periods, irrespective of the N stage. The integration of perioperative therapies to enhance surgical feasibility, especially the latest immunotherapy, holds particular promise for further survival benefits.

Navigating the landscape of neoadjuvant immunotherapy for NSCLC: progress and controversies

Recently, attention has increasingly centered on non-small-cell lung cancer (NSCLC) with immune checkpoint inhibitors application. Numerous clinical studies have underscored the potential of immunotherapy in treating resectable NSCLC, highlighting its role in improving patient outcomes. However, despite these promising results, there is ongoing debate regarding the efficacy of immunological combination therapy strategies, the prevalence of treatment-related side effects, the identification of predictive biomarkers, and various other challenges within the neoadjuvant context. Careful consideration is essential to maximize the benefits of immunotherapy for patients with resectable NSCLC. This article offers a detailed overview of recent advancements in neoadjuvant immunotherapy for resectable NSCLC. By examining these developments, we aim to provide new perspectives and valuable insights into the benefits and challenges of applying neoadjuvant immunotherapy in clinical settings.

Predicting therapeutic response to neoadjuvant immunotherapy based on an integration model in resectable stage IIIA (N2) non-small cell lung cancer

OBJECTIVE

Accurately predicting response during neoadjuvant chemoimmunotherapy for resectable non-small cell lung cancer remains clinically challenging. In this study, we investigated the effectiveness of blood-based tumor mutational burden (bTMB) and a deep learning (DL) model in predicting major pathologic response (MPR) and survival from a phase 2 trial.

METHODS

Blood samples were prospectively collected from 45 patients with stage IIIA (N2) non-small cell lung cancer undergoing neoadjuvant chemoimmunotherapy. An integrated model, combining the computed tomography-based DL score, bTMB, and clinical factors, was developed to predict tumor response to neoadjuvant chemoimmunotherapy.

RESULTS

At baseline, bTMB were detected in 77.8% (35 of 45) of patients. Baseline bTMB ≥11 mutations/megabase was associated with significantly greater MPR rates (77.8% vs 38.5%, P = .042), and longer disease-free survival (P = .043), but not overall survival (P = .131), compared with bTMB <11 mutations/megabase in 35 patients with bTMB available. The developed DL model achieved an area under the curve of 0.703 in all patients. Importantly, the predictive performance of the integrated model improved to an area under the curve of 0.820 when combining the DL score with bTMB and clinical factors. Baseline circulating tumor DNA (ctDNA) status was not associated with pathologic response and survival. Compared with ctDNA residual, ctDNA clearance before surgery was associated with significantly greater MPR rates (88.2% vs 11.1%, P < .001) and improved disease-free survival (P = .010).

CONCLUSIONS

The integrated model shows promise as a predictor of tumor response to neoadjuvant chemoimmunotherapy. Serial ctDNA dynamics provide a reliable tool for monitoring tumor response.

Major pathologic response predicts survival in resectable stage IIIA non-small cell lung cancer after neoadjuvant therapy

OBJECTIVES

Major pathologic response is more common in survival analyses than pathological complete response. Whether major pathologic response can predict survival of patients with resectable stage IIIA non-small cell lung cancer and whether neoadjuvant chemotherapy or immunochemotherapy affect the prognosis of patients remains questionable.

METHODS

Patients with resectable stage IIIA non-small cell lung cancer receiving neoadjuvant chemotherapy (≥2 cycles) with/without immunotherapy were enrolled and divided into two groups according to pathological response. Comparison between the two groups was through chi-square test. Univariate Cox regression analysis and log-rank test were made to identify predictive factors of overall survival and disease-free survival. Kaplan-Meier survival curves were constructed to evaluate the prognostic impact of these factors.

RESULTS

Totally, 38 patients were enrolled. Significant difference was observed in overall survival (P = 0.005) and disease-free survival (P = 0.007) between patients with/without major pathologic response. For patients failing to reach major pathologic response, those who underwent ≥2 cycles of neoadjuvant therapy exhibited improved outcomes in overall survival (P = 0.021) and disease-free survival (P = 0.046). Notably, within this subgroup, patients receiving ≥ 2 cycles of neoadjuvant immunochemotherapy showed a trend towards better overall survival (P = 0.076) and disease-free survival (P = 0.062).

CONCLUSIONS

Major pathologic response can predict survival of patients with resectable stage IIIA non-small cell lung cancer. For patients potentially not achieving major pathologic response after two cycles of neoadjuvant therapy, extended cycles of feasible neoadjuvant therapy are advisable for survival benefits.

Advances in molecular imaging and targeted therapeutics for lymph node metastasis in cancer: a comprehensive review

Lymph node metastasis is a critical indicator of cancer progression, profoundly affecting diagnosis, staging, and treatment decisions. This review article delves into the recent advancements in molecular imaging techniques for lymph nodes, which are pivotal for the early detection and staging of cancer. It provides detailed insights into how these techniques are used to visualize and quantify metastatic cancer cells, resident immune cells, and other molecular markers within lymph nodes. Furthermore, the review highlights the development of innovative, lymph node-targeted therapeutic strategies, which represent a significant shift towards more precise and effective cancer treatments. By examining cutting-edge research and emerging technologies, this review offers a comprehensive overview of the current and potential impact of lymph node-centric approaches on cancer diagnosis, staging, and therapy. Through its exploration of these topics, the review aims to illuminate the increasingly sophisticated landscape of cancer management strategies focused on lymph node assessment and intervention.

Lung autotransplantation for advanced central lung cancer after neoadjuvant immuno-chemotherapy: a case series study

Background

For locally advanced central lung cancer, lung autotransplantation allows for complete tumor resection while maximizing the preservation of lung parenchyma. Neoadjuvant chemotherapy combined with immunotherapy has shown benefits for patients with advanced lung cancer, providing longer progression-free survival compared to chemotherapy alone. This study aims to evaluate the feasibility and safety of neoadjuvant immuno-chemotherapy followed by lung autotransplantation in the treatment of locally advanced central non-small cell lung cancer (NSCLC).

Methods

We retrospectively analyzed ten patients with central NSCLC who underwent lung autotransplantation after neoadjuvant immuno-chemotherapy from June 2019 to December 2023. Of the grafts, there was 1 right upper lobe, 3 right lower lobe, 1 left lower lobe, 5 basal segments (3 right and 2 left). Nine cases were performed ex situ except one in situ without graft perfusion. All patients were followed up regularly.

Results

Ten cases received neoadjuvant immuno-chemotherapy [programmed cell death protein 1 (PD-1) inhibitor combined with platinum plus paclitaxel], the average number of cycles was 2.3±0.5 cycles, and the average interval between neoadjuvant therapy and surgery was 35.0±13.3 days. Following treatment, there was 1 complete response (CR), 6 partial responses (PRs), and 3 stable diseases (SDs). All cases achieved R0 resection, with 6 cases attaining complete pathological remission (CPR) and 2 cases exhibiting major pathological remission (MPR). No operative death occurred within 30 days. Six cases developed perioperative complications, with five cases being mild to moderate in severity, all of which recovered after standardized treatment. Only one instance of severe pulmonary artery embolism was observed, which improved with systemic anticoagulation therapy. The median follow-up time was 9.5 (range, 1.1-54.2) months. One patient had 4R lymph node recurrence (improved after radiotherapy and immunotherapy), and seven patients survived without recurrence.

Conclusions

Lung autotransplantation for advanced central NSCLC after neoadjuvant immuno-chemotherapy is feasible and safe, with maximal preservation of lung function and a high rate of R0 resection. This also demonstrates the advantages of organ preservation strategies. The procedure can be technically challenging, but lethal complications are uncommon. Overall, outcomes are satisfactory, and patients achieved reasonable survival during the follow-up period.

Prognosis prediction using significant pathological response following neoadjuvant immunotherapy in resectable non-small-cell lung tumors: a meta-analysis

Background

A meta-analysis study was done to figure out how to predict the prognosis of people with resectable non-small-cell lung cancer (NSCLC) who had a significant pathological response following neoadjuvant immunotherapy.

Methods

Up until August 2024, a comprehensive literature study was completed, and 2,386 connected studies were revised. The 35 selected studies included 3,118 resectable non-small-cell lung tumor participants at the beginning of the study. Using dichotomous techniques and a fixed or random model, the odds ratio (OR) and 95% confidence intervals (CIs) were used to assess the prediction using significant pathological response following neoadjuvant immunotherapy in resectable NSCLC.

Results

Individuals with resectable NSCLC had significantly higher major pathological response when comparing neoadjuvant chemo-immunotherapy to neoadjuvant chemotherapy (OR, 5.07; 95% CI, 4.09-6.27, p < 0.001), objective response rate to non-objective response rate (OR, 7.02; 95% CI, 4.28-11.50, p < 0.001), and programmed death-ligand 1 ≥1% to programmed death-ligand ≤1% (OR, 2.49; 95% CI, 1.44-4.30, p = 0.001). However, no significant difference was found in major pathological response between stage III and stage I-II (OR, 1.43; 95% CI, 0.88-2.33, p = 0.15), and squamous cell cancer and non-squamous cell cancer (OR, 1.35; 95% CI, 0.95-1.92, p = 0.09) in individuals with resectable NSCLCs.

Conclusion

Individuals with resectable NSCLCs had significantly higher major pathological response when comparing neoadjuvant chemo-immunotherapy to neoadjuvant chemotherapy, objective response rate to non-objective response rate, and programmed death-ligand 1≥1% to programmed death-ligand 1 ≤1%, however, no significant difference was found between stage III and stage I-II, and squamous cell cancer and non-squamous cell cancer. To validate this discovery, more research is required since most of the selected studies had a low sample size, and caution must be implemented when interacting with its values.

The time-to-surgery interval and its effect on pathological response after neoadjuvant chemoimmunotherapy in non-small cell lung cancer: a retrospective cohort study

Background

The time to surgery (TTS) after the completion of the final cycle of neoadjuvant chemoimmunotherapy in patients with non-small cell lung cancer (NSCLC) is inconsistent. Pathological complete response (pCR) and major pathological response (MPR) are associated with enhanced survival in those with NSCLC. The optimal TTS interval remains to be determined, some studies indicated that TTS ≤6 weeks has a vital role in NSCLC prognosis. Therefore, this study aimed to determine whether TTS is correlated with pathological outcomes and to identify the factors associated with TTS.

Methods

We retrospectively analyzed 82 individuals who had surgery after neoadjuvant chemoimmunotherapy for NSCLC between January 2020 and December 2023. Fifty participants were included in this study after inclusion and exclusion criteria. Participants were categorized into two groups: TTS ≤4 weeks and TTS >4 to 6 weeks. Univariate and multivariate regression analyses were employed to determine the impact of TTS on pathological response and to identify the variables associated with TTS. Variables that showed their P value <0.2 in univariate analyses were included in the multivariate analysis. Kaplan-Meier analysis was used to analyze disease-free survival (DFS).

Results

Our study evaluating 50 patients revealed that patients in the TTS ≤4 weeks group achieved pCR or MPR compared to patients in the >4 to 6 weeks group (P=0.01). In univariate analyses, TTS ≤4 weeks was more correlated with achieving pCR or MPR than TTS >4 to 6 weeks [odds ratio (OR) =0.211; 95% confidence interval (CI): 0.062-0.711; P=0.01] The multivariate analysis showed that cT1 stage (compared to cT4), and cN1 stage (compared to cN0) showed statistical correlation with achieving pCR or MPR. cN1 stage was independent predictor of achieving pCR or MPR (OR =27.817; 95% CI: 1.536-503.88; P=0.02). Concerning to the DFS, TTS ≤4 weeks group and TTS >4 to 6 weeks group showed no statistical differences (2-year DFS rate were 70.6% and 72.6%, respectively). Regarding the tendency of being patients' TTS ≤4 weeks, patients with ventilatory impairment (OR =0.203; 95% CI: 0.04-0.98; P=0.047) were more tending to prolong the TTS to >4 to 6 weeks.

Conclusions

TTS ≤4 weeks was associated with a significant improvement of pathological response. Therefore, patients with NSCLC should undergo surgery within 4 weeks after the last cycle of neoadjuvant chemoimmunotherapy.

Outcomes After Neoadjuvant Therapy With or Without Immunotherapy Followed By Pneumonectomy in Non-Small Cell Lung Cancer Patients

BACKGROUND

There are limited data concerning pneumonectomy after preoperative induction therapy. Our study aimed to evaluate feasibility and safety of pneumonectomy after neoadjuvant immunotherapy in patients with non-small cell lung cancer by assessing postoperative outcomes.

METHODS

A total of 1187 patients who underwent pneumonectomy for non-small cell lung cancer were retrospectively analyzed from 3 hospitals in China. Propensity score matching was adopted to form a balanced cohort between neoadjuvant therapy and non-neoadjuvant therapy groups. Univariable and multivariable logistic regression analyses were used to identify risk factors for postoperative morbidity. Efficacy and survival were compared for neoadjuvant therapy with or without immunotherapy.

RESULTS

The neoadjuvant group had larger tumors (4.7 ± 2.2 cm vs 3.9 ± 1.9 cm [P < .001]; cT4, 36.3% vs 19.1% [P < .001]), had a greater rate of N2 metastases (64.5% vs 33.3%; P < .001), and were at a more advanced clinical TNM stage (stage III, 89.4% vs 58.6%; P < .001). No significant difference in postoperative morbidity was observed between the groups before and after propensity score matching (43.5% vs 42.9% [P = .975]; 49.4% vs 41.9% [P = .162]). The complete pathologic response rate of neoadjuvant chemoimmunotherapy was significantly superior to that of chemotherapy alone (27.7% vs 2.0%; P < .001), and no significant difference in postoperative morbidity was observed in neoadjuvant therapy with or without immunotherapy. The neoadjuvant chemoimmunotherapy group also obtained a survival benefit with a 3-year overall survival (79.8% vs 67.5%; P = .001) and a 3-year event-free survival (63.3% vs 41.2%; P = .004).

CONCLUSIONS

After neoadjuvant therapy with immunotherapy, pneumonectomy can be safely performed in selected patients without increased postoperative morbidity.

Neoadjuvant and Adjuvant Treatments for Early Stage Resectable NSCLC: Consensus Recommendations From the International Association for the Study of Lung Cancer

Advances in the multidisciplinary care of early stage resectable NSCLC (rNSCLC) are emerging at an unprecedented pace. Numerous phase 3 trials produced results that have transformed patient outcomes for the better, yet these findings also require important modifications to the patient treatment journey trajectory and reorganization of care pathways. Perhaps, most notably, the need for multispecialty collaboration for this patient population has never been greater. These rapid advances have inevitably left us with important gaps in knowledge for which definitive answers will only become available in several years. To this end, the International Association for the Study of Lung Cancer commissioned a diverse multidisciplinary international expert panel to evaluate the current landscape and provide diagnostic, staging, and therapeutic recommendations for patients with rNSCLC, with particular emphasis on patients with American Joint Committee on Cancer-Union for International Cancer Control TNM eighth edition stages II and III disease. Using a team-based approach, we generated 19 recommendations, of which all but one achieved greater than 85% consensus among panel members. A public voting process was initiated, which successfully validated and provided qualitative nuance to our recommendations. Highlights include the following: (1) the critical importance of a multidisciplinary approach to the evaluation of patients with rNSCLC driven by shared clinical decision-making of a multispecialty team of expert providers; (2) biomarker testing for rNSCLC; (3) a preference for neoadjuvant chemoimmunotherapy for stage III rNSCLC; (4) equipoise regarding the optimal management of patients with stage II between upfront surgery followed by adjuvant therapy and neoadjuvant or perioperative strategies; and (5) the robust preference for adjuvant targeted therapy for patients with rNSCLC and sensitizing EGFR and ALK tumor alterations. Our primary goals were to provide practical recommendations sensitive to the global differences in biology and resources for patients with rNSCLC and to provide expert consensus guidance tailored to the individualized patient needs, goals, and preferences in their cancer care journey as these are areas where physicians must make daily clinical decisions in the absence of definitive data. These recommendations will continue to evolve as the treatment landscape for rNSCLC expands and more knowledge is acquired on the best therapeutic approach in specific patient and disease subgroups.

Does the number of cycles of neoadjuvant therapy affect the efficacy of neoadjuvant chemoimmunotherapy for non-small cell lung cancer in locally advanced stage? Retrospective experience based on a single center

BACKGROUND

The number of cycles of neoadjuvant therapy programmed cell death 1 (PD-1) inhibitor for locally advanced non-small cell lung cancer (NSCLC) remains controversial.

METHODS

From October 2019 to March 2022, neoadjuvant chemoimmunotherapy followed by radical surgery for NSCLC patients with stage II-III were retrospectively reviewed in Shanghai Pulmonary Hospital. The radiologic response was assessed according to the Response Evaluation Criteria for Solid Tumors version 1.1. The major pathological response was defined as no more than 10% residual tumor. Student's t-test, chi-square test, and Mann-Whitney test were used for univariate analysis, logistic regression analysis was used for multivariate analysis. All statistical analyses were calculated by SPSS software (version 26).

RESULTS

Among 108 patients, the number of patients who received 2-cycle (2-cycle group) and more than 2-cycle (>2-cycle group) neoadjuvant chemoimmunotherapy were 75 (69.4%) and 33 (30.6%), respectively. Compared with patients in the >2-cycle group, patients in the 2-cycle group had significantly smaller diagnostic radiological tumor size (37.0 mm vs. 49.6 mm, p = 0.022) and radiological tumor regression rate (36% vs. 49%, p = 0.007). However, no significant difference in pathological tumor regression rate was observed between patients in the 2-cycle group and >2-cycle group. Further logistic regression analysis demonstrated that the neoadjuvant chemoimmunotherapy cycle could independently affect the radiographic response (odds ratio [OR]: 0.173, 95% confidence interval [CI]: 0.051-0.584, p = 0.005) but not for pathological response (OR: 0.450, 95% CI: 0.161-1.257, p = 0.127).

CONCLUSIONS

For patients diagnosed with stage II-III NSCLC, the number of neoadjuvant cycles administered can significantly influence the radiographic efficacy of chemoimmunotherapy.

Safety and Efficacy of Neoadjuvant Chemoimmunotherapy versus Chemotherapy for Non-Small Cell Lung Cancer Undergoing Sleeve Resection

The prognosis of locally advanced non-small cell lung cancer (NSCLC) remains poor despite the addition of neoadjuvant chemotherapy, as it has been shown to improve 5-year absolute benefit survival by only 5%. Recently, neoadjuvant immunotherapy with immune checkpoint inhibitors (ICIs), combined with chemotherapy has shown promise in the treatment of locally advanced NSCLC. For NSCLC invading the main bronchus, sleeve resection has become the preferred modality to avoid pneumonectomy and reserve more cardiac or pulmonary function and to reduce postoperative morbidity and mortality. However, there has been a paucity of evidence to evaluate the safety and efficacy of neoadjuvant chemoimmunotherapy on bronchial-vascular reconstruction owing to the limited number of patients treated by sleeve lobectomy. Despite promising initial results, key knowledge gaps remain, including the impact on bronchial-vascular reconstruction, biomarkers predictive of ICI response, and the potential for specific perioperative complications associated with neoadjuvant chemoimmunotherapy in the context of sleeve resection. This review summarizes the latest literature evidence on the efficacy and safety of neoadjuvant chemoimmunotherapy approaches to address the unmet needs of sleeve resection of NSCLC treatment, describes the biomarkers predictive of ICI responses, and perioperative outcomes of sleeve resection after neoadjuvant chemoimmunotherapy.

Perioperative Predictive Factors for Tumor Regression and Survival in Non-Small Cell Lung Cancer Patients Undergoing Neoadjuvant Treatment and Lung Resection

Our study aimed to identify predictors for the effectiveness of tumor regression in lung cancer patients undergoing neoadjuvant treatment and cancer resections. Patients admitted between 2016 and 2022 were included in the study. Based on the histology of the tumor, patients were categorized into a lung adenocarcinoma group (LUAD) and squamous cell carcinoma group (SQCA). Ninety-five patients with non-small-cell lung cancer were included in the study. A total of 58 (61.1%) and 37 (38.9%) patients were included in the LUAD and SQCA groups, respectively. Additionally, 9 (9.5%), 56 (58.9%), and 30 (31.6%) patients were categorized with a tumor regression score of I, II, and III, respectively. In multivariable analyses, histology of the primary tumor (SQCA), lymph node size in the preoperative CT scan (>1.7 cm), and absolute tumor size reduction after neoadjuvant treatment (>2.6 cm) independently predict effectiveness of tumor regression (OR [95% confidence interval, p-value] of 6.88 [2.40-19.77, p < 0.0001], 3.13 [1.11-8.83, p = 0.0310], and 3.76 [1.20-11.81, p = 0.0233], respectively). Age > 70 years, extended resection > one lobe, and tumor recurrence or metastasis were identified as significant independent predictors of reduced overall survival. Assessment of tumor size before and after neoadjuvant treatment might help to identify high-risk patients with decreased survival and to improve patient management and care.

Neoadjuvant cabozantinib restores CD8+ T cells in patients with locally advanced non-metastatic clear cell renal cell carcinoma: a phase 2 trial

Cabozantinib is an oral multikinase inhibitor approved for treatment in metastatic renal cell carcinoma (RCC). We hypothesized that neoadjuvant cabozantinib could downstage localized tumors, facilitating partial nephrectomy, and facilitating surgery in patients with locally advanced tumors that would require significant adjacent organ resection. We, therefore, conducted a phase 2, single-arm trial of cabozantinib treatment for 12 weeks in 17 patients with locally advanced biopsy-proven non-metastatic clear cell RCC before surgical resection. Six patients (35%) experienced a partial response, and 11 patients (65%) had stable disease. We identified that plasma cell-free DNA (cfDNA), VEGF, c-MET, Gas6, and AXL were significantly increased while VEGFR2 decreased during cabozantinib treatments. There was a trend towards CD8+ T cells becoming activated in the blood, expressing the proliferation marker Ki67 and activation markers HLA-DR and CD38. Cabozantinib treatment depleted myeloid populations acutely. Importantly, immune niches made up of the stem-like CD8+ T cells and antigen presenting cells were increased in every patient. These data suggest that cabozantinib treatment was clinically active and safe in the neoadjuvant setting in patients with locally advanced non-metastatic clear cell RCC and activated the anti-tumor CD8+ T cell response. The trial is registered at ClinicalTrials.gov under registration no. NCT04022343.

Analysis of surgical complexity and short-term prognostic indicators in NSCLC patients: neoadjuvant targeted therapy versus neoadjuvant chemoimmunotherapy

Background

Neoadjuvant therapy improves survival benefits in patients with locally advanced non-small cell lung cancer but increases tissue density, presenting challenges for surgeons.

Objectives

To compare the differences in surgical complexity and short-term prognostic outcomes between neoadjuvant targeted therapy (NTT) and neoadjuvant chemoimmunotherapy (NCI).

Design/methods

This study enrolled 106 patients underwent curative surgery after neoadjuvant therapy between January 2020 and December 2023 at the National Cancer Center of China. Differences in surgical complexity and short-term prognostic outcomes between the two neoadjuvant therapy cohorts were evaluated. The pathological indicators such as pathological response rate and lymph node upstaging/downstaging were then analyzed.

Results

In total, 33 patients underwent NTT and 73 underwent NCI preoperatively. Patients who received NTT showed a higher minimally invasive surgery rate (84.8% versus 53.4%, p < 0.01), shorter operative time (144 versus 184 min, p < 0.01), lower conversion rate (3.3% versus 17.8%, p = 0.03), less postoperative drainage (day 3: 140 versus 200 mL, p = 0.03), and lower incidence of postoperative complications including arrhythmias (6.1% versus 26%, p = 0.02). The pathological response rate in the NTT and NCI groups was 70% and 75%, respectively, with the latter group showing a higher complete pathological response rate. The two groups had no significant differences in major pathological response and lymph node pathological response rate.

Conclusion

Patients who received NTT presented fewer surgical challenges for surgeons and had better surgical outcomes than those who received NCI therapy, with comparable pathological response rates between the two cohorts. Accordingly, NTT is the preferred induction regimen for patients harboring mutation status.

Neoadjuvant camrelizumab (an anti-PD-1 antibody) plus chemotherapy or apatinib (a VEGFR-2 inhibitor) for initially unresectable stage II-III non-small-cell lung cancer: a multicentre, two-arm, phase 2 exploratory study

This multicentre, two-arm, phase 2 study aimed to explore the efficacy and safety of neoadjuvant camrelizumab plus chemotherapy or apatinib in patients with initially unresectable stage II-III non-small-cell lung cancer (NSCLC). Eligible patients regardless of PD-L1 expression received neoadjuvant camrelizumab 200 mg and platinum-doublet chemotherapy every 3 weeks (arm A) or those with PD-L1-positive tumors received neoadjuvant camrelizumab and apatinib 250 mg once daily (arm B), for 2-4 cycles, followed by surgery. The primary endpoint was major pathological response (MPR) rate. Thirty patients in arm A and 21 in arm B were enrolled. Surgery rates were 50.0% (15/30) in arm A and 42.9% (9/21) in arm B, with all patients achieving R0 resections. Of these patients, the MPR and pathological complete response rates were both 20.0% (95% CI 4.3-48.1) in arm A and were 55.6% (95% CI 21.2-86.3) and 11.1% (95% CI 0.3-48.2) in arm B, respectively. The corresponding objective response rates were 33.3% (95% CI 11.8-61.6) and 55.6% (95% CI 21.2-86.3). With a median follow-up of 22.4 months (95% CI 19.0-26.0), the median event-free survival was not reached (NR; 95% CI 13.6-NR) in arm A and 16.8 months (95% CI 8.6-NR) in arm B. Grade 3 or above treatment-related adverse events occurred in eight (26.7%) patients in arm A and three (14.3%) in arm B. Biomarker analysis showed baseline TYROBP expression was predictive of treatment response in arm B. Neoadjuvant camrelizumab plus chemotherapy or apatinib exhibits preliminary efficacy and manageable toxicity in patients with initially unresectable stage II-III NSCLC.

Surgery challenges and postoperative complications of lung cancer after neoadjuvant immunotherapy

BACKGROUND

In China, real-world data on surgical challenges and postoperative complications after neoadjuvant immunotherapy of lung cancer are limited.

METHODS

Patients were retrospectively enrolled from January 2018 to January 2023, and their clinical and pathological characters were subsequently analyzed. Surgical difficulty was categorized into a binary classification according to surgical duration: challenging or routine. Postoperative complications were graded using Clavien-Dindo grades. Logistic regression was used to identify risk factors affecting the duration of surgery and postoperative complications greater than Clavien-Dindo grade 2.

RESULTS

In total, 261 patients were included. Of these, stage III patients accounted for 62.5% (163/261) at initial diagnosis, with 25.3% (66/261) at stage IIIB. Central-type non-small-cell lung cancer accounted for 61.7% (161/261). One hundred and forty patients underwent video-assisted thoracoscopic surgery and lobectomy accounted for 53.3% (139/261) of patients. Surgical time over average duration was defined as challenging surgeries, accounting for 43.7%. The postoperative complications rate of 261 patients was only 22.2%. Smoking history (odds ratio [OR] = 9.96, 95% [CI] 1.15-86.01, p = 0.03), chemoimmunotherapy (OR = 2.89, 95% CI 1.22-6.86, p = 0.02), and conversion to open surgery (OR = 11.3, 95% CI 1.38-92.9, p = 0.02) were identified as independent risk factors for challenging surgeries, while pneumonectomy (OR = 0.36, 95% CI 0.15-0.86, p= 0.02) was a protective factor. Meanwhile, pneumonectomy (OR = 7.51, 95% CI 2.40-23.51, p < 0.01) and challenging surgeries (OR = 5.53, 95% CI 1.50-20.62, p = 0.01) were found to be risk factors for postoperative complications greater than Clavien-Dindo grade 2.

CONCLUSIONS

Compared to immunotherapy alone or in combination with apatinib, neoadjuvant chemoimmunotherapy could increase the difficulty of surgery while the incidence of postoperative complications remained acceptable. The conversion to open surgery and pneumonectomy after neoadjuvant immunotherapy should be reduced.

Local therapy combined with anti-PD-1 immunotherapy for advanced lung adenocarcinoma: A case report

ABSTRACT

Lung adenocarcinoma (LUAD) encompasses all lung epithelial cancers except small-cell lung cancer. Although programmed cell death protein 1 (PD-1) inhibitors, such as pembrolizumab, and other Food and Drug Administration-approved immune checkpoint inhibitors, offer new hope for LUAD treatment, LUAD's overall efficacy remains limited. Thus, the combination of immunotherapy with other therapeutic approaches has gained widespread attention. Local therapy is an optimal method for treating many advanced unresectable lung cancers. Herein, we present a case of a patient with multiple metastases from LUAD, who attained complete response for more than 3 years until present through local therapy combined with a PD-1 inhibitor.

Easily applicable predictive score for MPR based on parameters before neoadjuvant chemoimmunotherapy in operable NSCLC: a single-center, ambispective, observational study

BACKGROUND

Neoadjuvant chemoimmunotherapy (NACI) is promising for resectable nonsmall cell lung cancer (NSCLC), but predictive biomarkers are still lacking. The authors aimed to develop a model based on pretreatment parameters to predict major pathological response (MPR) for such an approach.

METHODS

The authors enrolled operable NSCLC treated with NACI between March 2020 and May 2023 and then collected baseline clinical-pathology data and routine laboratory examinations before treatment. The efficacy and safety data of this cohort was reported and variables were screened by Logistic and Lasso regression and nomogram was developed. In addition, receiver operating characteristic curves, calibration curves, and decision curve analysis were used to assess its power. Finally, internal cross-validation and external validation was performed to assess the power of the model.

RESULTS

In total, 206 eligible patients were recruited in this study and 53.4% (110/206) patients achieved MPR. Using multivariate analysis, the predictive model was constructed by seven variables, prothrombin time (PT), neutrophil percentage (NEUT%), large platelet ratio (P-LCR), eosinophil percentage (EOS%), smoking, pathological type, and programmed death ligand-1 (PD-L1) expression finally. The model had good discrimination, with area under the receiver operating characteristic curve (AUC) of 0.775, 0.746, and 0.835 for all datasets, cross-validation, and external validation, respectively. The calibration curves showed good consistency, and decision curve analysis indicated its potential value in clinical practice.

CONCLUSION

This real world study revealed favorable efficacy in operable NSCLC treated with NACI. The proposed model based on multiple clinically accessible parameters could effectively predict MPR probability and could be a powerful tool in personalized medication.

Single-port video-assisted thoracoscopic sleeve lobectomy after neoadjuvant immunochemotherapy: a case report

Background

The morbidity and mortality of lung cancer have always ranked first among malignant tumors (MTs). Previous studies have shown that neoadjuvant chemotherapy can improve the 5-year survival rate of patients with non-small cell lung cancer (NSCLC), but the benefit is limited. Studies have proven that neoadjuvant immunotherapy combined with chemotherapy has unique advantages in prolonging patient survival, reducing distant recurrence, and inducing antitumor immunity. However, its impact remains to be more comprehensively investigated.

Case Description

A 59-year-old male who was admitted to the hospital with a primary complaint of repeated cough and expectoration for 6 months. Preoperative assessment showed right upper lung squamous cell carcinoma with multiple hilar and mediastinal lymph node metastasis, and the clinical stage was cT2aN2M0 stage (IIIA). After three cycles of pembrolizumab + carboplatin + paclitaxel therapy were administered, the reexamination of the tumor was evaluated as partial response (PR), and a sleeve lobectomy of the right upper lung was performed under single-port thoracoscopic surgery. The operation proceeded smoothly without conversion to thoracotomy, and R0 resection was successfully achieved. Postoperative pathological stage was ypT1bN0M0 stage IA, and postoperative pathological remission was evaluated as major pathological response (MPR). After the operation, three cycles of immunotherapy combined with chemotherapy were completed, which was followed by maintenance therapy with pembrolizumab monotherapy for 1 year, and no signs of tumor recurrence and metastasis have been found in follow-up thus far.

Conclusions

Through this case, we believe that for locally advanced NSCLC sleeve lobectomy after neoadjuvant therapy may be a safe and feasible treatment option, can avoid pneumonectomy, protect the lung function of patients, and still ensure the R0 resection rate. Moreover, it may does not significantly increase the difficulty of surgical operation or reduce safety. However, further research is needed to confirm our conclusion. And then, neoadjuvant therapy in the perioperative period may induce a series of side effects or adverse reactions, and thus greater attention should be paid to its timely management.

Predictors, surrogate, and patient-reported outcomes in immunotherapy and salvage surgery for unresectable lung cancer: a single-center retrospective study

Medical treatment has changed drastically in recent years, especially for advanced stages of non-small-cell lung cancer (NSCLC), for which the development of immunotherapy and molecular targeted therapy significantly increased survival and quality of life. This single-center retrospective study aimed to analyze the outcome predictors, the surrogate outcomes, and the patient-reported outcomes after neoadjuvant immunotherapy for initially unresectable NSCLC. Patients affected by an initially unresectable NSCLC and identified between March 2014 and December 2021 who received immunotherapy alone or in combination with platinum-based chemotherapy and/or radiotherapy were collected. Overall survival (OS) and disease-free survival (DFS) were estimated according to the Kaplan-Meier method. Patient-reported outcomes were recorded using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life (QoL) Group questionnaire-Lung Cancer 29 Module to compare differences in symptoms and QoL at two different times, 30 days and 1 year after surgery. Surgical, pathological records, and patient-reported outcomes (at 30 days and 1 year after surgery) were reviewed. Complete pathological remission was achieved in 7 patients (36.8%) and major pathological remission in 3 patients (15.7%). The median overall survival in the study group is 19 months (range: 2-57.4). Of 19 patients, 16 (84.2%) are alive to date, of which 2 (10.5%) have a local recurrence. At 30 days from surgery, the main symptoms reported by EORTC Module were coughing, shortness of breath, the side effect of treatment, fear of progression, and surgery-related problems. Induction immunotherapy with or without chemotherapy can be considered for unresectable locally advanced NSCLC, and after the downstaging, the possibility of surgery could be re-evaluated in a multidisciplinary setting with high rates of R0 resection. In this selected and highly motivated group of patients, the QoL and symptoms after salvage surgeries are acceptable and even better than those reported in the literature.

Clinical utility of [18F]FDG PET/CT in the assessment of mediastinal lymph node disease after neoadjuvant chemoimmunotherapy for non-small cell lung cancer

OBJECTIVES

The performance of positron emission tomography/computed tomography (PET/CT) for the prediction of ypN2 disease in non-small cell lung cancer (NSCLC) after neoadjuvant chemoimmunotherapy has not been reported. This multicenter study investigated the utility of PET/CT to assess ypN2 disease in these patients.

METHODS

A total of 181 consecutive patients (chemoimmunotherapy = 86, chemotherapy = 95) at four institutions were enrolled in this study. Every patient received a PET/CT scan prior to surgery and complete resection with systematic nodal dissection. The diagnostic performance was evaluated through area under the curve (AUC). Kaplan-Meier method and Cox analysis were performed to identify the risk factors affecting recurrences.

RESULTS

The sensitivity, specificity, and accuracy of PET/CT for ypN2 diseases were 0.667, 0.835, and 0.779, respectively. Therefore, the AUC was 0.751. Compared with the false positive cases, the mean value of max standardized uptake value (SUVmax) (6.024 vs. 2.672, p < 0.001) of N2 nodes was significantly higher in true positive patients. Moreover, the SUVmax of true positive (7.671 vs. 5.976, p = 0.365) and false (2.433 vs. 2.339, p = 0.990) positive cases were similar between chemoimmunotherapy and chemotherapy, respectively. Survival analysis proved that pathologic N (ypN) 2 patients could be stratified by PET/CT-N2(+ vs. -) for both chemoimmunotherapy (p = 0.023) and chemotherapy (p = 0.010).

CONCLUSIONS

PET/CT is an accurate and non-invasive test for mediastinal restaging of NSCLC patients who receive neoadjuvant chemoimmunotherapy. The ypN2 patients with PET/CT-N2( +) are identified as an independent prognostic factor compared with PET/CT-N2(-).

CLINICAL RELEVANCE STATEMENT

Imaging with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) plays an integral role during disease diagnosis, staging, and therapeutic response assessments in patients with NSCLC. PET/CT could be an effective non-invasive tool for predicting ypN2 diseases after neoadjuvant chemoimmunotherapy.

KEY POINTS

• PET/CT could serve as an effective non-invasive tool for predicting ypN2 diseases. • The ypN2 patients with PET/CT-N2( +) were a strong and independent prognostic factor. • The application of PET/CT for restaging should be encouraged in clinical practice.

Efficacy, safety, and survival of neoadjuvant immunochemotherapy in operable non-small cell lung cancer: a systematic review and meta-analysis

Background

Neoadjuvant immunochemotherapy may benefit patients with non-small cell lung cancer (NSCLC), but its impact requires further investigation.

Methods

A meta-analysis was conducted. PubMed, Embase, Web of Science, and the Cochrane Library were searched. The study was registered in PROSPERO (registration no. CRD42022360893).

Results

60 studies of 3,632 patients were included. Comparing with neoadjuvant chemotherapy, neoadjuvant immunochemotherapy showed higher pCR (RR: 4.71, 95% CI: 3.69, 6.02), MPR (RR, 3.20, 95% CI: 2.75, 3.74), and ORR (RR, 1.46, 95% CI: 1.21, 1.77), fewer surgical complications (RR: 0.67, 95%CI: 0.48, 0.94), higher R0 resection rate (RR: 1.06, 95%CI: 1.03, 1.10, I2 = 52%), and longer 1-year and 2-year OS, without affecting TRAEs. For neoadjuvant immunochemotherapy in NSCLC, the pooled pCR rate was 0.35 (95% CI: 0.31, 0.39), MPR was 0.59 (95% CI: 0.54, 0.63), and ORR was 0.71 (95% CI: 0.66, 0.76). The pooled incidence of all grade TRAEs was 0.70 (95% CI: 0.60, 0.81), and that of >= grade 3 TRAEs was 0.24 (95% CI: 0.16, 0.32). The surgical complications rate was 0.13 (95% CI: 0.07, 0.18) and R0 resection rate was 0.98 (95% CI: 0.96, 0.99). The pooled 1-year OS was 0.97 (95%CI: 0.96, 0.99), and 2-year OS was 0.89 (95%CI: 0.83, 0.94). Patients with squamous cell carcinoma, stage III or higher PD-L1 performed better. Notably, no significant differences were observed in pCR, MPR, and ORR between 2 or more treatment cycles. Pembrolizumab-, or toripalimab-based neoadjuvant immunochemotherapy demonstrated superior efficacy and tolerable toxicity.

Conclusion

According to our analysis, reliable efficacy, safety, and survival of neoadjuvant immunochemotherapy for operable NSCLC were demonstrated.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022360893, identifier CRD42022360893.

Survival Effect of Surgery in Patients with Stage IIIB/N2 Non-small Cell Lung Cancer: A Comparative Study with Definitive Chemoradiotherapy

OBJECTIVE

We compared the survival outcomes of surgery within multimodality treatment regimens with the outcomes of definitive chemoradiation treatments in patients diagnosed with clinical (c) IIIB/N2 non-small cell lung cancer (NSCLC). We investigated whether surgery within multimodality treatment provides a survival advantage at this stage.

MATERIAL AND METHODS

Data from 79 patients with cIIIB/N2 between 2009 and 2016 were analyzed retrospectively. While the surgery was performed after neoadjuvant therapy in 51 cases (IIIB/Surgery Group), definitive chemotherapy ± radiotherapy was applied in 28 cases (IIIB/Definitive Group).

RESULTS

In cIIIB/N2 cases, the 5-year overall survival (OS) was 27.4%, with a median OS of 24.6 months. The 5-year OS of the IIIB/ Surgery Group was 27.3% (median survival 22.5 months), while it was 28.6% (median survival 29.1 months) in the IIIB/Definitive Group (P = .387, HR = 0.798, 95% CI, 0.485-1.313). Although there was a survival advantage in the group with a pathological complete response (PCR) after surgery (n = 14) compared to the group that did not (n = 37), the observed difference was not statistically significant. (5-year OS; 42.9% vs. 18.5%, P = .104). Additionally, there was no statistically significant difference between the survival of PCR patients and the IIIB/Definitive Group in terms of OS (P = .488).

CONCLUSION

Surgery performed within multimodality treatment regimens in selected cIIIB/N2 cases did not provide a survival advantage over definitive chemoradiation treatments.

Neoadjuvant Immunotherapy and Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

To systematically evaluate the effectiveness and safety of neoadjuvant immunotherapy for patients with non-small cell lung cancer (NSCLC).

METHODS

Randomized controlled trials of neoadjuvant immunotherapy in treating patients with NSCLC were comprehensively retrieved from electronic databases, eligible studies, previous systematic reviews and meta-analyses, guidelines, and conference abstracts. The meta-analysis was performed by the Stata/SE 12.0 software.

RESULTS

Eleven randomized controlled trials were eventually included. The results of the meta-analysis showed that neoadjuvant immunochemotherapy significantly improved the objective response rate compared with neoadjuvant chemotherapy (CT; 62.46% vs 41.88%, P = 0.003), but the objective response rate of neoadjuvant double-immunotherapy was roughly comparable to that of neoadjuvant single-immunotherapy (15.74% vs 10.45%, P = 0.387). Major pathologic response (MPR) rate and pathologic complete response (pCR) rate of neoadjuvant immunochemotherapy and neoadjuvant double-immunotherapy were significantly superior to neoadjuvant CT alone and neoadjuvant single-immunotherapy, respectively. Compared with neoadjuvant CT alone, neoadjuvant immunochemotherapy increased the down-staging rate (40.16% vs 26.70%, P = 0.060), the surgical resection rate (83.69% vs 73.07%, P = 0.231), and R0 resection rate (86.19% vs 77.98%, P = 0.502), but there were no statistically significant differences. Neoadjuvant immunochemotherapy did not increase the postoperative complications rate than neoadjuvant CT alone (40.20% vs 41.30%, P = 0.920). In terms of safety, neoadjuvant immunochemotherapy and neoadjuvant double-immunotherapy did not increase the incidence of treatment-related adverse events (TRAEs) and the grade 3 or higher TRAEs.

CONCLUSIONS

In summary, neoadjuvant immunochemotherapy had better clinical efficacy than neoadjuvant CT for patients with NSCLC. MPR rate and pCR rate of neoadjuvant immunochemotherapy and neoadjuvant double-immunotherapy were significantly superior to neoadjuvant CT and neoadjuvant single-immunotherapy, respectively, for patients with NSCLC, showing that MPR rate and pCR rate were probably considered as alternative endpoints for survival benefit. TRAEs were comparable between the corresponding groups. The long-term survival outcome of neoadjuvant immunotherapy for patients with NSCLC needs to be further confirmed to better guide clinical practice.

Identification of ACHE as the hub gene targeting solasonine associated with non-small cell lung cancer (NSCLC) using integrated bioinformatics analysis

Background

Solasonine, as a major biological component of Solanum nigrum L., has demonstrated anticancer effects against several malignancies. However, little is understood regarding its biological target and mechanism in non-small cell lung cancer (NSCLC).

Methods

We conducted an analysis on transcriptomic data to identify differentially expressed genes (DEGs), and employed an artificial intelligence (AI) strategy to predict the target protein for solasonine. Subsequently, genetic dependency analysis and molecular docking were performed, with Acetylcholinesterase (ACHE) selected as a pivotal marker for solasonine. We then employed a range of bioinformatic approaches to explore the relationship between ACHE and solasonine. Furthermore, we investigated the impact of solasonine on A549 cells, a human lung cancer cell line. Cell inhibition of A549 cells following solasonine treatment was analyzed using the CCK8 assay. Additionally, we assessed the protein expression of ACHE, as well as markers associated with apoptosis and inflammation, using western blotting. To investigate their functions, we employed a plasmid-based ACHE overexpression system. Finally, we performed dynamics simulations to simulate the interaction mode between solasonine and ACHE.

Results

The results of the genetic dependency analysis revealed that ACHE could be identified as the pivotal target with the highest docking affinity. The cell experiments yielded significant findings, as evidenced by the negative regulatory effect of solasonine treatment on tumor cells, as demonstrated by the CCK8 assay. Western blotting analysis revealed that solasonine treatment resulted in the downregulation of the Bcl-2/Bax ratio and upregulation of cleaved caspase-3 protein expression levels. Moreover, we observed that ACHE overexpression promoted the expression of the Bcl-2/Bax ratio and decreased cleaved caspase-3 expression in the OE-ACHE group. Notably, solasonine treatment rescued the Bcl-2/Bax ratio and cleaved caspase-3 expression in OE-ACHE cells compared to OE-ACHE cells without solasonine treatment, suggesting that solasonine induces apoptosis. Besides, solasonine exhibited its anti-inflammatory effects by inhibiting P38 MAPK. This was supported by the decline in protein levels of IL-1β and TNF-α, as well as the phosphorylated forms of JNK and P38 MAPK. The results from the molecular docking and dynamics simulations further confirmed the potent binding affinity and effective inhibitory action between solasonine and ACHE.

Conclusions

The findings of the current investigation show that solasonine exerts its pro-apoptosis and anti-inflammatory effects by suppressing the expression of ACHE.

Neoadjuvant therapy does not increase postoperative morbidity of sleeve lobectomy in locally advanced non-small cell lung cancer

OBJECTIVES

To evaluate the feasibility and safety of sleeve lobectomy after neoadjuvant therapy by assessing the postoperative morbidity.

METHODS

Patients who underwent sleeve lobectomy for non-small cell lung cancer (NSCLC) were retrospectively analyzed from January 2018 to December 2021. A total of 613 patients were enrolled, including 124 patients who received previous neoadjuvant therapy and 489 patients who did not. Propensity score matching was adopted to create a balanced cohort consisting of 97 paired cases. Patient demographics and perioperative outcomes were compared between the 2 groups, and logistic regression analysis was used to identify risk factors for postoperative complications.

RESULTS

In the entire cohort, univariable logistic regression analysis showed that smoking history (odds ratio [OR], 1.501; 95% confidence interval [CI], 1.011-2.229, P = .044), open thoracotomy (OR, 1.748; 95% CI, 1.178-2.593, P = .006), and operation time more than 150 minutes (OR, 1.548; 95% CI, 1.029-2.328, P = .036) were risk factors for postoperative complications, and multivariable logistic regression analysis showed open thoracotomy was an independent risk factor (OR, 1.765; 95% CI, 1.178-2.643, P = .006). In the balanced cohort, the neoadjuvant group had a lower proportion of double-sleeve resections (3.1% vs 11.3%, P = .035) and longer postoperative chest tube drainage (6.67 ± 3.81 vs 5.13 ± 3.74 days, P < .001). However, no significant differences were observed in postoperative morbidity between the 2 groups (25.8% vs 24.7%, P = .869). The complete pathologic response of chemoimmunotherapy was significantly superior to chemotherapy alone (28.2% vs 4.1%, P < .001), and no significant differences were noted in postoperative morbidity in different neoadjuvant therapy modalities.

CONCLUSIONS

After neoadjuvant therapy, sleeve lobectomy can be safely performed with no increased postoperative morbidity.

Neoadjuvant sintilimab combined with chemotherapy in resectable locally advanced non-small cell lung cancer: case series and literature review

BACKGROUND

In recent years, neoadjuvant immunotherapy with chemotherapy has shown increasing promise for locally advanced non-small cell lung cancer (NSCLC). However, to establish its clinical efficacy and safety, it is imperative to amass more real-world clinical data. This retrospective study aims to assess the safety and effectiveness of combing sintilimab, a PD-1 inhibitor, with chemotherapy as a neoadjuvant treatment modality in patients diagnosed with potentially resectable NSCLC.

METHODS

We retrospectively reviewed patients with stage II-III NSCLC receiving neoadjuvant chemoimmunotherapy in Sichuan Cancer Hospital between February 2021 and February 2023. Sintilimab injection (intravenously,200 mg, iv, d1, q3w) and platinum-based chemotherapy were administered intravenously every 3 weeks, with radical lung cancer resection planned approximately 4-11 weeks after the last dose. The primary endpoint of the study was pathologic complete response (pCR). The secondary endpoints were objective response rate (ORR), and safety.

RESULT

Thirteen patients were enrolled, they were mostly diagnosed with stage III NSCLC (IIB 15.4% IIIA 38.5%; IIIB 46.2%). Most of them had pathologically confirmed squamous cell carcinoma (69.2%). All patients received sintilimab combined with platinum-based chemotherapy for 2 to 4 cycles. Notably, none of the patients necessitated a reduction in initial dosages or treatment postponement due to intolerable adverse events. Then, all of them underwent surgical operation. Impressively, nine patients (69.2%) achieved a pathologic complete response. The objective response rate (ORR) stood at 46.15%. Nine patients experienced neoadjuvant treatment-related adverse events (TRAEs), with only one patient (7.6%) encountering a grade 4 neoadjuvant TRAE.

CONCLUSION

Therefore, the current study suggested that neoadjuvant sintilimab plus platinum-based chemotherapy can be a safe approach in increasing the efficiency of treatment and hopefully improving the prognosis of patients with potentially resectable locally advanced NSCLC.

Does major pathological response after neoadjuvant Immunotherapy in resectable nonsmall-cell lung cancers predict prognosis? A systematic review and meta-analysis

OBJECTIVE

Overall survival is the gold-standard outcome measure for phase 3 trials, but the need for a long follow-up period can delay the translation of potentially effective treatment to clinical practice. The validity of major pathological response (MPR) as a surrogate of survival for non small cell lung cancer (NSCLC) after neoadjuvant immunotherapy remains unclear.

METHODS

Eligibility was resectable stage I-III NSCLC and delivery of PD-1/PD-L1/CTLA-4 inhibitors prior to resection; other forms/modalities of neoadjuvant and/or adjuvant therapies were allowed. Statistics utilized the Mantel-Haenszel fixed-effect or random-effect model depending on the heterogeneity ( I2 ).

RESULTS

Fifty-three trials (seven randomized, 29 prospective nonrandomized, 17 retrospective) were identified. The pooled rate of MPR was 53.8%. Compared to neoadjuvant chemotherapy, neoadjuvant chemo-immunotherapy achieved higher MPR (OR 6.19, 4.39-8.74, P <0.00001). MPR was associated with improved disease-free survival/progression-free survival/event-free survival (HR 0.28, 0.10-0.79, P =0.02) and overall survival (HR 0.80, 0.72-0.88, P <0.0001). Patients with stage III (vs I/II) and PD-L1 ≥1% (vs <1%) more likely achieved MPR (OR 1.66,1.02-2.70, P =0.04; OR 2.21,1.28-3.82, P =0.004).

CONCLUSIONS

The findings of this meta-analysis suggest that neoadjuvant chemo-immunotherapy achieved higher MPR in NSCLC patients, and increased MPR might be associated with survival benefits treated with neoadjuvant immunotherapy. It appears that the MPR may serve as a surrogate endpoint of survival to evaluate neoadjuvant immunotherapy.

Is response evaluation criteria in solid tumors (RECIST) effective in patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC?

BACKGROUND

Neoadjuvant immunotherapy combined with chemotherapy has been used to treat locally advanced non-small cell lung cancer (NSCLC). Several systems have been developed for response evaluation. The aim of this study was to evaluate the predictive value of response evaluation criteria in solid tumors (RECIST) and propose modified RECIST (mRECIST).

METHODS

Eligible patients received chemotherapy combined with personalized neoadjuvant immunotherapy. Radical resection was subsequently performed for potentially resectable tumors evaluated by RECIST. The resected specimens were evaluated to determine the response to neoadjuvant therapy.

RESULTS

A total of 59 patients received radical resection following neoadjuvant immunotherapy combined with chemotherapy. According to RECIST, four patients had complete remission, 41 had partial remission, and 14 had progressive disease. Postoperative pathological examination showed 31 patients achieved complete pathological remission, and 13 achieved major pathological remission. The final pathological results were uncorrelated with RECIST assessment (p = 0.086). The ycN stage and pN stage were irrelevant (p < 0.001). When the cutoff of sum of diameters (SoD) is 17%, the Youden's index reached its highest value. A correlation was found between mRECIST and final pathological results. Patients with squamous cell lung cancer showed higher proportions in objective response (OR) (p < 0.001) and complete pathological remission (CPR) (p = 0.001). A shorter time to surgery (TTS) was correlated with a better OR (p = 0.014) and CPR (p = 0.010). The decrease in SoD was correlated with better OR (p = 0.008) and CPR (p = 0.002).

CONCLUSIONS

mRECIST was effective for patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC. Two modifications were suggested for RECIST: (1) the cutoff value was adjusted to 17% for partial remission. (2) Changes in lymph nodes on computed tomography were eliminated. A shorter TTS, a larger decrease in SoD and squamous cell lung cancer (vs. adenocarcinoma) were correlated with better pathological responses.

Copy number variations mediate major pathological response to induction chemo-immunotherapy in unresectable stage IIIA-IIIB lung cancer

INTRODUCTION

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Despite this, evidence supporting optimal management of certain stages remains a topic of debate. In this retrospective study we examine the efficacy and safety, as well as exploring the biomarkers of neoadjuvant induction immuno-chemotherapy, in Chinese patients with unresectable stage III NSCLC.

METHODS

Patients with unresectable stage III NSCLC who were identified as driver mutation-negative and who received neoadjuvant chemo-immunotherapy were enrolled from three Chinese hospitals between Jan. 17, 2019, and Jan.17, 2022. Perioperative outcomes and survival data were collected. Retrospective biomarker exploration was performed in available baseline tumor samples and surgical specimens.

RESULTS

94 patients were enrolled and received chemo-immunotherapy as neoadjuvant treatment. 80 patients had squamous cell carcinoma, and 26 had stage IIIB disease. Surgery conversion rate was 74.4%, R0 resection rate was 98.4%. Of 64 patients who underwent surgery, major pathological response (MPR) rate was 65.6% and pathologic complete response (pCR) rate was 42.2%. 73% of patients with N2 disease demonstrated down-staging to N0. Treatment-related adverse events (TRAEs) occurred in 43 patients (45.7%) with anemia was the most common. The Grade ≥ 3 TRAEs rate was 3.2% (3/94). A significant association between copy number variation (CNV) ploidy was also found.

CONCLUSION

The combination treatment of immuno-chemotherapy for unresectable stage III NSCLC is not only effective but also has a favourable safety profile. For the first time we provide evidence that CNV status may be a predictive biomarker of MPR.

Utility of 18F-FDG PET/CT uptake values in predicting response to neoadjuvant chemoimmunotherapy in resectable non-small cell lung cancer

INTRODUCTION

Reliable predictive markers are lacking for resectable non-small cell lung cancer (NSCLC) patients treated with neoadjuvant chemoimmunotherapy. The present study investigated the utility of SUV_max values acquired from PET/CT to predict the response to neoadjuvant chemoimmunotherapy for resectable NSCLC.

MATERAL AND METHODS

SUV_max, clinical and pathological outcomes, were collected from patients in 5 hospitals. Patients who received dynamic PET/CT surveillance were divided into cohorts A (chemoimmunotherapy) and B (chemotherapy), respectively, while cohort C (chemoimmunotherapy) comprised patients undergoing post-therapy PET/CT. Associations between SUV_max and major pathologic response (MPR) were evaluated through receiver operating characteristic (ROC) curves.

RESULTS

A total of 129 cases with an MPR rate of 46.5 % was identified. In neoadjuvant chemoimmunotherapy, ΔSUV_max% (AUC: 0.890, 95 % CI: 0.761-0.949) and post-therapy SUV_max (AUC: 0.933, 95 % CI: 0.802-0.959) could accurately predict MPR. On the contrary, the baseline SUV_max was not associated with MPR (p = 0.184). Furthermore, an independent cohort C proved that post-therapy SUV_max could serve as an independent predictor (AUC: 0.928, 95 % CI: 0.823-0.958). In addition, robust predictive performance could be observed when we use the optimal cut-off point of both ΔSUV_max% (54.4 %, AUC: 0.912, 95 % CI: 0.824-0.994) and post-therapy SUV_max (3.565, AUC: 0.912, 95 % CI: 0.824-0.994) in neoadjuvant chemoimmunotherapy. The RNA data revealed that the expression of PFKFB4, a key enzyme in glycolysis, was positively correlated with SUV_max value and tumor cell proliferation after neoadjuvant chemoimmunotherapy.

CONCLUSION

These findings highlighted that the ΔSUV_max% and remained SUV_max were accurate and non-invasive tests for the prediction of MPR after neoadjuvant chemoimmunotherapy.

Adjuvant and neo-adjuvant immunotherapy in resectable non-small cell lung cancer (NSCLC): Current status and perspectives

Surgery followed by adjuvant chemotherapy is the standard of care for selected patients with early-stage or locally advanced non-small cell lung cancer (NSCLC). However, many of these patients still experience postoperative recurrence at 5 years. At present, peri-operative treatment methods are emerging to prevent early relapse, such as targeted therapy and immunotherapy. Investigation on predictive biomarkers of responses to adjuvant and neoadjuvant therapies is also continuously ongoing. Immunotherapy represented by immune checkpoint inhibitors (ICIs), either by monotherapy or in combination with chemotherapy, has shown benefit in promoting pathological responses and prolonging survival for patients with NSCLC without oncogenic mutations. Exploratory studies have also provided evidence regarding the selection of patients who benefit from ICI-based perioperative treatment. This review focuses on the existing data of current clinical trials of adjuvant and neoadjuvant strategies with ICIs in resectable NSCLC, the exploration of predictive biomarkers, and the perspectives and urgent challenges in the future.

A novel nomogram to predict lymph node metastasis in cT1 non-small-cell lung cancer based on PET/CT and peripheral blood cell parameters

BACKGROUND

Accurately evaluating the lymph node status preoperatively is critical in determining the appropriate treatment plan for non-small-cell lung cancer (NSCLC) patients. This study aimed to construct a novel nomogram to predict the probability of lymph node metastasis in clinical T1 stage patients based on non-invasive and easily accessible indicators.

METHODS

From October 2019 to June 2022, the data of 84 consecutive cT1 NSCLC patients who had undergone PET/CT examination within 30 days before surgery were retrospectively collected. Univariate and multivariate logistic regression analyses were performed to identify the risk factors of lymph node metastasis. A nomogram based on these predictors was constructed. The area under the receiver operating characteristic (ROC) curve and the calibration curve was used for assessment. Besides, the model was confirmed by bootstrap resampling.

RESULTS

Four predictors (tumor SUVmax value, lymph node SUVmax value, consolidation tumor ratio and platelet to lymphocyte ratio) were identified and entered into the nomogram. The model indicated certain discrimination, with an area under ROC curve of 0.921(95%CI 0.866-0.977). The calibration curve showed good concordance between the predicted and actual possibility of lymph node metastasis.

CONCLUSIONS

This nomogram was practical and effective in predicting lymph node metastasis for patients with cT1 NSCLC. It could provide treatment recommendations to clinicians.

CDC25C Protein Expression Correlates with Tumor Differentiation and Clinical Outcomes in Lung Adenocarcinoma

Given that, even after multimodal therapy, early-stage lung cancer (LC) often recurs, novel prognostic markers to help guide therapy are highly desired. The mRNA levels of cell division cycle 25C (CDC25C), a phosphatase that regulates G2/M cell cycle transition in malignant cells, correlate with poor clinical outcomes in lung adenocarcinoma (LUAD). However, whether CDC25C protein detected by immunohistochemistry can serve as a prognostic marker in LUAD is yet unknown. We stained an LC tissue array and a cohort of 61 LUAD tissue sections for CDC25C and searched for correlations between CDC25C staining score and the pathological characteristics of the tumors and the patients' clinical outcomes. Clinical data were retrieved from our prospectively maintained departmental database. We found that high expression of CDC25C was predominant among poorly differentiated LUAD (p < 0.001) and in LUAD > 1cm (p < 0.05). Further, high expression of CDC25C was associated with reduced disease-free survival (p = 0.03, median follow-up of 39 months) and with a trend for reduced overall survival (p = 0.08). Therefore, high expression of CDC25C protein in LUAD is associated with aggressive histological features and with poor outcomes. Larger studies are required to further validate CDC25C as a prognostic marker in LUAD.

Progress and perspectives of perioperative immunotherapy in non-small cell lung cancer

Lung cancer is one of the leading causes of cancer-related death. Lung cancer mortality has decreased over the past decade, which is partly attributed to improved treatments. Curative surgery for patients with early-stage lung cancer is the standard of care, but not all surgical treatments have a good prognosis. Adjuvant and neoadjuvant chemotherapy are used to improve the prognosis of patients with resectable lung cancer. Immunotherapy, an epoch-defining treatment, has improved curative effects, prognosis, and tolerability compared with traditional and ordinary cytotoxic chemotherapy, providing new hope for patients with non-small cell lung cancer (NSCLC). Immunotherapy-related clinical trials have reported encouraging clinical outcomes in their exploration of different types of perioperative immunotherapy, from neoadjuvant immune checkpoint inhibitor (ICI) monotherapy, neoadjuvant immune-combination therapy (chemoimmunotherapy, immunotherapy plus antiangiogenic therapy, immunotherapy plus radiotherapy, or concurrent chemoradiotherapy), adjuvant immunotherapy, and neoadjuvant combined adjuvant immunotherapy. Phase 3 studies such as IMpower 010 and CheckMate 816 reported survival benefits of perioperative immunotherapy for operable patients. This review summarizes up-to-date clinical studies and analyzes the efficiency and feasibility of different neoadjuvant therapies and biomarkers to identify optimal types of perioperative immunotherapy for NSCLC.

Progress on neoadjuvant immunotherapy in resectable non-small cell lung cancer and potential biomarkers

Immune checkpoint inhibitors (ICIs) are highly concerned in the treatment of non-small cell lung cancer (NSCLC), represented by inhibitors of programmed death protein 1 (PD-1) and its ligand (PD-L1), and inhibitors of cytotoxic T lymphocyte-associated antigen-4 (CTLA-4). The introduction of immunotherapy in the treatment of perioperative NSCLC has improved the prognosis to a great extent, as demonstrated by several phase II and III clinical trials. The target population for immunotherapy in early-stage NSCLC is still under discussion, and the biomarkers for neoadjuvant immunotherapy population selection are the next pending problem. The predictive efficacy of many potential makers is still being explored, including PD-L1 expression levels, tumor mutation burden, circulating tumor DNA, components of the tumor microenvironment, and several clinical factors. We summarize key findings on the utility of ICIs in clinical trials of preoperative NSCLC patients and conclude analyses of relevant biomarkers to provide a better understanding of potentially predictive biomarkers in neoadjuvant immunotherapy.

Efficacy and safety evaluation of neoadjuvant immunotherapy plus chemotherapy for resectable non-small cell lung cancer in real world

Objectives

The combination of immunotherapy and chemotherapy has shown great efficacy in stage IV non-small cell lung cancer (NSCLC) and is now widely used in clinical treatment strategy. This study retrospectively analyzed the efficacy and safety of neoadjuvant immunotherapy plus chemotherapy for resectable NSCLC in real world.

Methods

We retrospectively analyzed patients with NSCLC who received neoadjuvant immunotherapy plus chemotherapy and underwent complete tumor resection in Zhejiang Cancer Hospital between January 2019 and January 2021. Tumor staging was based on the eighth TNM classification system of the American Joint Committee on Cancer staging criteria. The safety and toxicity (including operative and postoperative complications) and the efficacy [including objective response rate (ORR), disease control rate (DCR), tumor major pathological remission (MPR), and pathological complete response (pCR)] were evaluated.

Results

In total, 368 patients with NSCLC were administered with neoadjuvant immunotherapy. Of them, 211 patients were included in this retrospective study. Most patients had stage II-III disease, with 75 (35.5%) and 88 (41.7%) patients diagnosed with clinical stages IIB and IIIA, respectively. A total of 206 patients (97.6%) received at least two doses of neoadjuvant immunotherapy plus chemotherapy. In addition, 121 patients (57.3%) have achieved MPR, and 80 patients (37.9%) have achieved pCR, with ORR at 69.2% and DCR at 97.7%. Treatment-related adverse events occurred in 46.4% of patients, and the incidence rate of grade 3 or 4 treatment-related adverse events was 13.3% (13/98). Moreover, adverse events of any grade of surgical complication occurred in 15.6% of patients. One-year disease-free survival was 80.6% (170/211).

Conclusions

Neoadjuvant immunotherapy plus chemotherapy has significant efficacy with a high pCR and tolerable adverse effects for patients with resectable stage II-III NSCLC in real world.

Correlations between contrast-enhanced ultrasound and microvessel density in non-small cell lung cancer: A prospective study

Background

Immunohistochemical microvessel density (MVD) is an early indicator of angiogenesis and it could be used to evaluate the therapeutic efficacy of non-small cell lung cancer (NSCLC). We sought to identify the ability of contrast-enhanced ultrasound (CEUS) in evaluating MVD of subpleural NSCLC.

Methods

We prospectively collected CEUS data of NSCLC confirmed by ultrasound-guided transthoracic needle biopsy from October 2019 to February 2021, The MVD of NSCLC counted by CD34-positive vessels of immunohistochemical staining. Microflow enhancement (MFE) of CEUS was divided into "dead wood", "cotton", and "vascular" patterns. Pathology subgroup and MVD between different MFE patterns were analyzed, respectively. The arrival time, time to peak, peak intensity (PI), and area under curve (AUC) derivefrom time-intensity curve of CEUS with MVD in NSCLC and its pathological subgroups (adenocarcinoma and squamous cell carcinoma) were subjected to correlation analysis.

Results

A total of 87 patients were included in this study, consisting of 53 cases of adenocarcinoma and 34 cases of squamous cell carcinoma with a mean MVD of 27.8 ± 12.2 mm^-1. There was a significant statistical difference in MFE patterns between two pathological subgroups (p < 0.05). Besides, the MVD of "cotton" and "vascular" patterns were significantly higher than that of "dead wood" pattern (both of p < 0.05), whereas there was no significant difference in MVD between "cotton" pattern and "vascular" pattern. PI and AUC of CEUS were positively correlated with the MVD of NSCLC (r = 0.497, p < 0.001, and r = 0.367, p < 0.001, respectively). Besides, PI and AUC of CEUS were positively correlated with the MVD of squamous cell carcinoma (r = 0.802, and r = 0.663, respectively; both of p < 0.001). Only the PI was positively correlated with the MVD of lung adenocarcinoma (r = 0.288, p = 0.037).

Conclusions

MFE patterns and quantitative parameters of CEUS had good correlation with MVD of NSCLC, especially in squamous cell carcinoma.

Non-small cell lung cancer in China

In China, lung cancer is a primary cancer type with high incidence and mortality. Risk factors for lung cancer include tobacco use, family history, radiation exposure, and the presence of chronic lung diseases. Most early-stage non-small cell lung cancer (NSCLC) patients miss the optimal timing for treatment due to the lack of clinical presentations. Population-based nationwide screening programs are of significant help in increasing the early detection and survival rates of NSCLC in China. The understanding of molecular carcinogenesis and the identification of oncogenic drivers dramatically facilitate the development of targeted therapy for NSCLC, thus prolonging survival in patients with positive drivers. In the exploration of immune escape mechanisms, programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor monotherapy and PD-1/PD-L1 inhibitor plus chemotherapy have become a standard of care for advanced NSCLC in China. In the Chinese Society of Clinical Oncology's guidelines for NSCLC, maintenance immunotherapy is recommended for locally advanced NSCLC after chemoradiotherapy. Adjuvant immunotherapy and neoadjuvant chemoimmunotherapy will be approved for resectable NSCLC. In this review, we summarized recent advances in NSCLC in China in terms of epidemiology, biology, molecular pathology, pathogenesis, screening, diagnosis, targeted therapy, and immunotherapy.

Impact of the interval between neoadjuvant immunochemotherapy and surgery on surgical–pathological outcomes in non-small cell lung cancer

Introduction

The interval between neoadjuvant immunochemotherapy and surgery in patients with non-small cell lung cancer (NSCLC) has not been well characterized. This study investigated the association between the time-to-surgery (TTS) interval and surgical–pathological outcomes.

Method

Clinical data of patients who received neoadjuvant immun-ochemotherapy followed by surgery for NSCLC between January 2019 and September 2021 were collected. The patients were divided into three groups based on TTS interval: the early-surgery group (ESG), the standard-surgery group (SSG), and the delayed-surgery group (DSG). The primary outcomes were objective response rate (ORR), major pathological response (MPR), and pathological complete response (pCR). The secondary endpoint was surgical outcome.

Results

Of the 171 patients, 16 (9.4%) received surgery in ≤28 days, 49 (28.7%) received surgery within 29–42 days, and 106 (61.9%) received surgery in ≥43 days after neoadjuvant immunochemotherapy, with a median TTS of 46 days. The postoperative drainage of the ESG group (455.1 ml) was significantly less than that of the SSG group (680.7 ml) and the DSG group (846.5 ml; p = 0.037). However, the TTS interval did not influence the duration of the operation (P = 0.54), the extent of intraoperative bleeding (P = 0.60), or the length of postoperative hospital stay (P = 0.17). The ORR was observed in 69%, 51%, and 56% of patients in the ESG, the SSG, and the DSG, respectively (P = 0.46), and MPR occurred in 50%, 47%, and 58% (P = 0.38) of patients in the ESG, the SSG, and the DSG, respectively. Similarly, no statistically significant difference was found for pCR (ESG: 31%; SSG: 27%; DSG: 42%; P = 0.14).

Conclusion

This retrospective study indicated that TTS exerts no significant effect on the feasibility and safety of surgery in the neoadjuvant immunochemotherapy setting of NSCLC. Analysis of the TTS interval revealed a tendency for delayed surgery to be associated with a pathological response in NSCLC, although this association was not statistically significant.

Neoadjuvant chemoradiotherapy with camrelizumab in patients with locally advanced esophageal squamous cell carcinoma

Background

Neoadjuvant anti-programmed death receptor-1 (PD-1) blockade has been reported to improve the prognosis of locally advanced esophageal squamous cell carcinoma (ESCC). This study was aimed to evaluate the efficacy and safety of neoadjuvant camrelizumab plus chemoradiotherapy in locally advanced ESCC.

Methods

We retrospectively enrolled ESCC patients who received camrelizumab plus chemoradiotherapy as neoadjuvant therapy before surgery from May 2019 to September 2021.

Results

A total of 38 eligible patients were enrolled. The neoadjuvant treatment was well tolerated with no serious treatment-related adverse events. 36 (94.7%) patients achieved a R0 resection without hospital mortality or any other serious intraoperative complications. The objective response rate (ORR) was 63.2% and the disease control rate (DCR) was 100.0%. The major pathological response (MPR) was 50.0% and the complete pathological response (pCR) was 39.5%. With a median follow-up of 18.5 months, 6 (15.8%) patients had died. The overall survival (OS) and disease-free survival (DFS) at 12 months were 87.6% and 78.7%, respectively. Subgroup analysis demonstrated that patients who got MPR or pCR achieved improved survival, while PD-L1 expression did not reach statistically difference in predicting survival.

Conclusions

Neoadjuvant camrelizumab plus chemoradiotherapy is safe and efficacious in treating patients with locally advanced ESCC.

[Progress of Neoadjuvant Immunotherapy for Non-small Cell Lung Cancer]

Neoadjuvant immunotherapy, including neoadjuvant single- or dual-drug immunotherapy or combined immunotherapy with chemotherapy or radiotherapy, has witnessed a rapid development in non-small cell lung cancer. Clinical trials exhibited the encouraging pathological responses and certain clinical benefits in selected patients, with tolerable toxicity. Nivolumab with chemotherapy has been approved by Food and Drug Administration (FDA) as the first immunotherapy-based treatment for non-small cell lung cancer in the neoadjuvant treatment setting. There is the need for further evaluation of long-term efficacy, side effects or surgical issues for neoadjuvant immunotherapy in non-small cell lung cancer.
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The Safety and Efficacy of Neoadjuvant Camrelizumab Plus Chemotherapy in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma: A Retrospective Study

Background

Neoadjuvant anti-programmed death receptor-1 (PD-1) blockade has been explored in the treatment of locally advanced esophageal squamous cell carcinoma (ESCC). We conducted this study to assess the efficacy and safety of neoadjuvant camrelizumab plus chemotherapy in locally advanced ESCC.

Methods

We retrospectively enrolled ESCC patients who received surgery within 3 months of treatment with camrelizumab plus chemotherapy from June 2019 to January 2021.

Results

A total of 34 eligible patients were enrolled. The neoadjuvant treatment was well tolerated with no serious treatment-related adverse events. Thirty-two (94.1%) patients achieved a R0 resection, and 14 patients (41.2%) developed postoperative complications. The objective response rate (ORR) was 61.8% and the disease control rate (DCR) was 100.0%. The major pathological response (MPR), pathological complete response (pCR), and clinical to pathological downstaging rate were 50.0%, 35.3%, and 79.4%, respectively. With a median follow-up of 14.8 months, 30 (88.2%) patients who underwent surgical resection remain alive. The disease-free survival (DFS) and overall survival (OS) at 12 months were 86.4% and 92.8%, respectively.

Conclusion

Neoadjuvant camrelizumab plus chemotherapy is safe and efficacious in treating patients with locally advanced ESCC.

Neoadjuvant treatment in non-small cell lung cancer: New perspectives with the incorporation of immunotherapy

The aim of neoadjuvant treatment in non-small cell lung cancer (NSCLC) is to eliminate micrometastatic disease to facilitate surgical resection. Neoadjuvant chemotherapy (ChT) in localised NSCLC has numerous advantages over other therapeutic modalities and is considered standard treatment in resectable disease. Treatment with immune checkpoint inhibitors (ICI) improves long-term survival in advanced disease and has a better toxicity profile than conventional therapies. These immunotherapy agents (anti-PD1/PD-L1), administered with or without ChT, are currently being evaluated in the preoperative setting, with initial results showing better pathological response rates and more long-term benefits. Importantly, these drugs do not appear to increase the rate of severe adverse effects and/or postoperative complications. However, several questions still need to be resolved, including the identification of predictive biomarkers; comparative studies of immunotherapy alone vs combined treatment with ChT and/or radiotherapy; the optimal duration of treatment; the timing of surgery; the need for adjuvant treatment; appropriate radiologic evaluation and mediastinal staging; and the correlation between pathological response and survival outcomes. Here we review the current evidence for immunotherapy from a multidisciplinary perspective and discuss current and future controversies.

Imaging immunity in patients with cancer using positron emission tomography

Immune checkpoint inhibitors and related molecules can achieve tumour regression, and even prolonged survival, for a subset of cancer patients with an otherwise dire prognosis. However, it remains unclear why some patients respond to immunotherapy and others do not. PET imaging has the potential to characterise the spatial and temporal heterogeneity of both immunotherapy target molecules and the tumor immune microenvironment, suggesting a tantalising vision of personally-adapted immunomodulatory treatment regimens. Personalised combinations of immunotherapy with local therapies and other systemic therapies, would be informed by immune imaging and subsequently modified in accordance with therapeutically induced immune environmental changes. An ideal PET imaging biomarker would facilitate the choice of initial therapy and would permit sequential imaging in time-frames that could provide actionable information to guide subsequent therapy. Such imaging should provide either prognostic or predictive measures of responsiveness relevant to key immunotherapy types but, most importantly, guide key decisions on initiation, continuation, change or cessation of treatment to reduce the cost and morbidity of treatment while enhancing survival outcomes. We survey the current literature, focusing on clinically relevant immune checkpoint immunotherapies, for which novel PET tracers are being developed, and discuss what steps are needed to make this vision a reality.

Real-world clinical outcomes of neoadjuvant immunotherapy combined with chemotherapy in resectable non-small cell lung cancer

OBJECTIVES

Early stage non-small cell lung cancer (NSCLC) patients who undergo complete resection continue to demonstrate high risk of recurrence and death. The advent of the neoadjuvant regimen has brought new hope for these patients. The present study aims to further demonstrate the efficacy of neoadjuvant chemoimmunotherapy.

MATERIALS AND METHODS

A real-world observational study was conducted concerning patients who received neoadjuvant pembrolizumab or nivolumab combined with chemotherapy between January 2018 and December 2020 in Shanghai Pulmonary Hospital. The primary endpoint was major pathologic response (MPR), and the secondary endpoints were objective response rate (ORR), pathologic complete response (pCR), disease-free survival (DFS) and toxicity.

RESULTS

A total of 76 patients were analyzed and divided into the pembrolizumab (n = 42) and nivolumab groups (n = 34) with a median follow-up time of 12.2 months. Most patients (92%) had stage III disease, with 41 (54%) and 29 (38%) patients initially diagnosed clinical stage IIIA and IIIB, respectively. Fifty (66%), 21 (28%) and 5 (6%) patients received two, three and four cycles of neoadjuvant treatment, separately, achieving an ORR of 75%. None of them needed a reduced initial dose or delay due to intolerable adverse events. Forty-nine (64%) and 28 (37%) patients achieved MPR and pCR, respectively. RNA sequencing showed that MPR associated with increased infiltration of cytotoxic immune cells with tertiary lymphoid structures (TLSs). Histological evaluation highlighted the localization of B cells within TLSs. Forty-two (69%) patients with clinically N2 disease at baseline were downstaged to pathological N0 (39 patients) or N1 (3 patients). One-year-PFS rate of stage III patients was 91%. No difference in baseline characteristics and treatment outcomes was observed between 2 groups.

CONCLUSION

The feasibility of neoadjuvant chemoimmunotherapy for resectable NSCLC was further validated, with a high MPR rate and manageable adverse events.