Early NSCLC Research Articles

EP02.04-009 Real World Survival Outcome Analysis of Adjuvant Therapies in Non-EGFR, Non-ALK Early Stage Resected NSCLC

Multiple clinical trials and meta-analyses have demonstrated the benefit of adjuvant chemotherapy for patients with early-stage resected NSCLC. Using a real-world registry of patients with early-stage NSCLC, we evaluated the effects of adjuvant chemotherapy, adjuvant radiation, and adjuvant chemoradiation on overall survival (OS).

Metabolism-Related Gene Expression in Circulating Tumor Cells from Patients with Early Stage Non-Small Cell Lung Cancer.

Simple SummaryIn the present study, the expression of three Metabolism-Related Enzymes (MRGs) that are related to glucose and pyruvate metabolism, in parallel with glucose and monocarboxylate transporter expression (HK2, MCT1, PHGDH), was studied in CTCs isolated from the peripheral blood of early stage NSCLC patients at different timepoints. The expression levels of all tested MRGs decreased in CTCs one month after surgery, but a significant increase was noticed at the time of relapse for PHGDH and MCT1 only. An overexpression of MRGs was observed at a high frequency in the CTCs isolated from early NSCLC patients, thereby supporting the role of MRGs in metastatic processes. The glycolytic and mesenchymal subpopulation of CTCs was significantly predominant compared to CTCs that wereglycolytic but not mesenchymal-like. Our data indicate that MRGs merit further evaluation through large and well-defined cohort studies.Purpose: Metabolic reprogramming is now characterized as one of the core hallmarks of cancer, and it has already been shown that the altered genomic profile of metabolically rewired cancer cells can give valuable information. In this study, we quantified three Metabolism-Related Gene (MRG) transcripts in the circulating tumor cells (CTCs) of early stage NSCLC patients and evaluated their associations with epithelial and EMT markers. Experimental Design: We first developed and analytically validated highly sensitive RT-qPCR assays for the quantification of HK2, MCT1 and PHGDH transcripts, and further studied the expression of MRGs in CTCs that were isolated using a size-dependent microfluidic device (Parsortix, Angle) from the peripheral blood of: (a) 46 NSCLC patients at baseline, (b) 39/46 of these patients one month after surgery, (c) 10/46 patients at relapse and (d) 10 pairs of cancerous and adjacent non-cancerous FFPE tissues from the same NSCLC patients. Epithelial and EMT markers were also evaluated. Results: MCT1 and HK2 were differentially expressed between HD and NSCLC patients. An overexpression of MCT1 was detected in 15/46 (32.6%) and 3/10 (30%) patients at baseline and at progression disease (PD), respectively, whereas an overexpression of HK2 was detected in 30.4% and 0% of CTCs in the same group of samples. The expression levels of all tested MRGs decreased in CTCs one month after surgery, but a significant increase was noticed at the time of relapse for PHGDH and MCT1 only. The expression levels of HK2 and MCT1 were associated with the overexpression of mesenchymal markers (TWIST-1 and VIM). Conclusion: An overexpression of MRGs was observed at a high frequency in the CTCs isolated from early NSCLC patients, thereby supporting the role of MRGs in metastatic processes. The glycolytic and mesenchymal subpopulation of CTCs was significantly predominant compared to CTCs that were glycolytic but not mesenchymal-like. Our data indicate that MRGs merit further evaluation through large and well-defined cohort studies.

A Real-World Systematic Analysis of Driver Mutations' Prevalence in Early- and Advanced-Stage NSCLC: Implications for Targeted Therapies in the Adjuvant Setting.

Simple SummaryThe development of oncogene-targeted drugs has radically changed the course of non small cell lung carcinoma (NSCLC) in the advanced stage. Recently, the ADAURA trial demonstrated the efficacy of Osimertinib also in the adjuvant setting of EGFR-mutated NSCLC. This raises the question regarding whether the same paradigm applies also to currently approved drugs directed against non-EGFR NSCLC drivers. Herein we compared actionable genomic alterations in early- and advanced-stage NSCLC in 1961 unselected single-institution cases analyzed by routine molecular diagnostics procedures. Our data add significantly to the currently limited real-world data on actionable mutations in surgically resectable NSCLC. Our finding that distinct NSCLC genomic drivers are mutated at similar frequencies in early- and advanced-stage tumors implies that the relative biological potency of currently actionable NSCLC genomic drivers is conserved throughout clinical evolution and supports the hypothesis that genotype-matched therapies are likely to provide significant benefit in an adjuvant settingThe approval of osimertinib for adjuvant treatment of stage I–II–III EGFR-mutated NSCLC (early stage) represents a paradigm shift, raising the question of whether other genotype-matched therapeutics approved for advanced-stage NSCLC can also provide clinical benefit in the adjuvant setting. However, there is a paucity of real-world data on the prevalence of actionable genomic alterations (GAs) in early-stage NSCLC. We used next-generation sequencing, complemented by immunohistochemistry and fluorescence in situ hybridization, to screen our single-institution cohort of 1961 NSCLC consecutive cases for actionable molecular targets. The prevalence of actionable GAs was comparable in early versus advanced-stage NSCLC, the only exception being KRAS mutations (more frequent in early-stage cases). Consistent with advanced-stage tumors being more aggressive, co-occurrence of TP53 and EGFR GAs as well as copy number gains were less frequent in early-stage tumors. EGFR mutations and high expression of PD-L1 were inversely associated, whereas KRAS mutations and high PD-L1 reactivity showed positive association. Recapitulating advanced-stage tumors, early-stage NSCLC had the highest share of EGFR mutations in lepidic and acinar subtypes. Resected lepidic tumors contained the highest proportion of the KRAS G12C actionable variant. These results, obtained with routine diagnostic technologies in an unselected clinical setting, provide a significant addition of real-world data in early-stage NSCLC.

Abstract 1394: Pervasive allele specific transcriptional repression of the class I and II HLA genes in TRACERx non-small cell lung cancer

Abstract Background: The adaptive immune system plays an important role in tumor evolution. A key source of cytotoxic T cell response in cancer is neoantigens, cancer cell specific mutations that result in mutant peptides that elicit a T cell mediated immune response. However, a mutation can only engender a neoantigen if the associated mutant peptide is presented to T cells by HLA molecules, and, as such, transcriptional repression or loss of the HLA genes can have important implications for immune evasion. Methods: We elucidate allele specific genomic and transcriptomic disruption to class I and II HLA genes. In whole exome sequencing (WES) data, our new tool (LOHHLA2.0) assesses loss of heterozygosity (LOH) status and somatic mutations. In RNA sequencing (RNAseq) data, LOHHLA2.0 quantifies allele specific expression and transcriptional repression referencing matched tumor adjacent normal samples. We applied LOHHLA2.0 to the TRACERx421 dataset, including 1554 WES tumor regions from 421 patients and 941 RNAseq regions from 357 tumor patients, 96 of which also had RNAseq from tumor adjacent normal samples. Results: We find that our method is more accurate than existing tools (RSEM) at calling gene level expression, e.g. in HLA-DPB1, RSEM under-calls HLA expression by a factor of two. 36% of TRACERx421 primary tumors harbored HLA LOH of at least one class I HLA gene, validating our previous findings in the TRACERx100 cohort. Strikingly, we found that 74% (71/96) of primary tumors with matched tumor adjacent normal tissue exhibited transcriptional repression of one or more class I HLA alleles, and 81% (78/96) exhibited class II allele transcriptional repression. Class I HLA transcriptional repression was more likely to occur subclonally than LOH. In a subset of tumors, we observed convergence upon disruption of the same allele through alternative mechanisms; with genomic loss in one tumor region and transcriptional repression in another region of the same tumor. Across the tumor regions, we found a concordance between HLA expression and immune infiltrate levels, with immune hot tumors exhibiting higher HLA class I expression. Conclusions: In this study, we find significant disruption to class I and II HLA expression adding to the diversity of immune evasion processes evident in early stage treatment naive NSCLC. Citation Format: Clare Puttick, Oriol Pich, Michelle Leung, Carlos Martinez-Ruiz, Robert Bentham, Rachel Rosenthal, Sonya Hessey, James R. Black, Emilia L. Lim, Katey Enfield, Emma Colliver, Krijn Dijkstra, Crispin T. Hiley, Takahiro Karasaki, Ariana Huebner, Maise Al Bakir, Thomas B. Watkins, Alexander M. Frankell, Simone Zaccaria, Mariam Jamal-Hanjani, Nicholas McGranahan, Charles Swanton. Pervasive allele specific transcriptional repression of the class I and II HLA genes in TRACERx non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1394.

A real-world (rw) evidence study quantifying the clinical value of multi-gene testing in early-stage lung adenocarcinoma (LUAD).

8525 Background: Resected early-stage NSCLC has high risk of recurrence, and tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICI), each requiring testing for precision biomarkers, have recently been approved in the adjuvant (adj) setting. We assessed the potential value of multi-gene testing in early NSCLC via enabling timely 1L therapy selection at recurrence and through avoidance of adj ICI in pts with driver alterations unlikely to benefit per current guidelines and the label for atezolizumab in first line (1L) NSCLC. Methods: Using the nationwide (̃280 US cancer clinics) de-identified EHR-derived rw Flatiron Health- Foundation Medicine clinico-genomic database, we selected 6,725 evaluable pts with LUAD who underwent tissue comprehensive genomic profiling (CGP) as part of routine cancer care (01/2011 – 06/2021). We focused on alterations in 4 drivers ( EGFR, ALK, ROS1, RET) and studied prevalence in early-stage specimens versus advanced (adv) specimens, as well as the rate of timely delivery of 1L therapy at recurrence for pts receiving CGP in early disease. We estimated the cost implications of adj ICI in pts with PD-L1+ LUAD and an ALK, ROS1, or RET fusion with a probabilistic decision tree. Results: CGP was performed on 1,490 specimens collected prior to adv disease (stage I 36%, II 27%, IIIA 37%) and ordered prior to adv diagnosis for 981 pts (15% of total, median 10 weeks after initial diagnosis). In specimens collected in early (n = 1,490) or adv (n = 5,130) stage LUAD, CGP identified drivers in EGFR (early/adv: 13%/16%), ALK (2.0%/4.2%), ROS1 (0.7%/1.1%), RET (1.0%/1.1%), and prevalence was similar when limiting to PD-L1+ cases. Studying 596 pts with recurrence and CGP on samples collected prior to recurrence, pts with CGP results obtained before (n = 196) vs after (n = 400) recurrence had less time between recurrence and start of any 1L therapy (median 3.1 vs 5.9 weeks, p < 0.001). In the subset with a targetable driver detected, 32/42 (76%) with CGP before recurrence initiated matched 1L TKI while 43/67 (64%) with CGP after recurrence received matched 1L TKI (p = 0.2). Through avoidance of ICI in PD-L1+ early LUAD with an ALK/ ROS1/ RET driver, we estimate universal CGP (compared to EGFR single-gene testing) could reduce per pt expected costs by $875 (an average incremental $4,050 treatment cost reduction compared to a $3,175 increase in diagnostic cost per pt). Conclusions: CGP of early-stage LUAD can identify EGFR, ALK, ROS1 and RET drivers and enable appropriate selection of precision therapies and timely use of effective 1L therapy at recurrence. Assuming adj ICI maintains the lack of activity in RET/ ROS1 as seen for ALK, CGP could represent a cost-effective approach for avoiding futile adj ICI and reducing the risk of subsequent TKI-associated toxicity. Additional analysis of driver+ pts receiving adj ICI is needed to help balance the risk/benefit for these high risk pts.

Efficacy of Adjuvant Chemotherapy With Tegafur-Uracil in Patients With Completely Resected, Node-Negative NSCLC—Real-World Data in the Era of Molecularly Targeted Agents and Immunotherapy

IntroductionIn Japan, adjuvant tegafur-uracil (UFT) chemotherapy is recommended for patients with completely resected, stage I NSCLC. This treatment requires real-world re-evaluation because of recent advances in target-based and immuno-oncological treatments and refinement of lung cancer staging. MethodsThe Japan Clinical Oncology Group (JCOG) 0707, a phase 3 trial comparing the benefits of UFT and S-1 (tegafur-gimeracil-oteracil) in patients with completely resected stage I NSCLC (T1 >2 cm and T2 in the TNM sixth edition), was conducted in Japan. A multicenter observational cohort study (Comprehensive Support Project for Oncology Research [CSPOR]-LC03) was also conducted for those patients excluded from JCOG 0707 during the study enrollment period. Physicians from institutions that participated in JCOG 0707 retrospectively assessed the medical records of each patient. The efficacy of UFT was evaluated in the CSPOR-LC03 cohort. ResultsIn the entire study population (n = 5005), patients treated with UFT (n = 1549) had significantly longer overall survival (OS) than those without any adjuvant chemotherapy (n = 3338). There was no significant difference in OS between the patients treated with UFT (n = 1061) and those without adjuvant chemotherapy (n = 1484) in the JCOG 0707-eligible population (logrank p = 0.755). For tumors without ground-glass attenuation and size greater than 3 cm, patients treated with UFT had significantly longer survival than those without adjuvant chemotherapy, on univariate but not on multivariate analysis. ConclusionsThere was no significant difference in OS between the patients treated with UFT and those without adjuvant chemotherapy in the clinical trial-eligible population. Adjuvant UFT for patients with completely resected NSCLC may be recommended only in patients with a tumor without ground-glass attenuation and size greater than 3 cm. In patients with node-negative early NSCLC, further study is needed to select patients who will benefit from adjuvant chemotherapy.

100P Physician perceptions of testing practices in patients with early and advanced stage EGFR mutation-positive (EGFRm) NSCLC: A global survey

Prevalence of EGFRm in NSCLC is estimated to be approximately 30%, although this varies by country and region. This global survey investigated physician behaviours related to genetic testing patterns in early (I/II/IIIa) and advanced (IIIb/IIIc/IV) stage NSCLC.

ES09.03 The Role of Biomarkers for Immunotherapy in the Adjuvant and Neoadjuvant Setting

For patients with NSCLC and absence of oncogenic addiction immune checkpoint inhibitors targeting PD1/PD-L1 change the therapeutic field. These treatments became standard of care in metastatic setting and are rapidly emerging in adjuvant and neoadjuvant setting. While more than 50% of patients with operable NSCLC will experience recurrence after surgery, neoadjuvant or adjuvant chemotherapy provides only a modest improvement in overall survival and could be highly toxic. Recent clinical trials underline the high rate of major pathological response in neoadjuvant setting and increase progression free survival in adjuvant setting. While such data will rapidly be practice changing immune checkpoint inhibitors are not effective in all patients and like in metastatic setting biomarkers remains unmet need. Various biomarkers are currently testing going from simple clinical biomarkers, to complex genomic and transcriptomic tests. Most biomarkers seem to behave similarly in adjuvant/neoadjuvant setting and in metastatic setting. Clinical patient’s characteristics are important to predict efficacy of adjuvant or neoadjuvant treatment. In IMPOWER 10 trial, testing adjuvant treatment with atezolizumab, oncogenic addiction with EGFR mutation or ALK translocation are associated with absence of efficacy of atezolizumab (1). Tumor with EGFR and ALK genomic alteration tumor are frequently poorly infiltrated in CD8 T cells and present poor level of mutations which render them resistant to immune checkpoint inhibitors. PD-L1 is also an important biomarker of efficacy in early NSCLC. In Checkmate 816 trial (2) which tests neoadjuvant chemotherapy versus nivolumab plus chemotherapy underlines that PD-L1 >1% is associated with higher rate of pathological complete response but nivolumab enhance efficacy of chemotherapy in either PD-L1 positive or negative tumors. In contrast in IMPOWER 10 trial (1), atezolizumab improves progression free survival only in patients with PD-L1 positive tumors. Efficacy proportionally increase with PD-L1 expression. Interestingly, similar observation was previously performed in PACIFIC trial (3). Importantly, a post-hoc analysis underlines that durvalumab give survival benefit only in PD-L1 positive patients raising question on this utility in this subset of patients. Smaller studies testing anti PD-1 alone or in association with anti CTLA-4 in neoadjuvant setting observed major responses irrespective of PD-L1 status (4,5). So, PD-L1 expression is an imperfect surrogate marker of hot tumors richly invaded by anti tumoral CD8 T cells. Such data underline the difficulty to use PD-L1 to avoid immune checkpoint inhibitors usage. In addition, PD-L1 assessment in neoadjuvant setting only relies on a tumor biopsy which is an imperfect surrogate marker of PD-L1 expression in the whole tumor. Tumor mutational burden (TMB) represents the total number of mutation found in coding region of cancer cell genome. High number of mutation is correlated with high capacity of cancer cells to present neoantigens, and cancers cells which present high level of neoantigen are more easily recognized by T cells. In CHECKMATE 816 (2) high TMB is associated with better response to neoadjuvant immunotherapy (pathological complete response of 22.44% for TMB low and 30.8% for TMB high). Similarly, in a small study using nivolumab and ipilimumab in neoadjvuvant setting, there was a significant correlation between the pathological response and the pretreatment TMB (5). Additional works are awaiting to determine if HLA status or intratumoral heterogeneity are also important to predict response to adjuvant or neoadjuvant immunotherapy like in metastatic setting. In addition to such classical biomarkers some emerging biomarkers are described in small cohort of neoadjuvant immunotherapy. Gut microbiome could influence response to checkpoint inhibitors by different mechanisms like modulation of tumor microenvironement or bacterial mimicry. In NEOSTAR trial (4), higher abundance of Akkermansia in baseline samples of gut microbiote is associated with better response to nivolumab + ipilimumab and is positively correlated with intratumoral immune response. Similarly, Akkermansia was also associated with favorable clinical outcomes in patients with melanoma, NSCLC and renal cell carcinoma receiving immunotherapy in metastatic setting thus confirming the important role of gut microbiota and akkermansia in the response to immunotherapy.

ES14.03 Liquid Biopsy and Early NSCLC Detection

Liquid biopsy is an extremely powerful tool in cancer patients with several potential applications that range from early cancer detection/cancer interception to real-time monitoring during anticancer therapies and tumor genotyping in advanced disease. Over the last few years great attention has been focused on early cancer detection, using different methodological approaches and liquid biopsy sources, including circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), metabolomics, and micro-RNAs.

1158P Real-world adjuvant treatment patterns and survival outcomes among early NSCLC US patients

While clinical trials have demonstrated survival benefits with adjuvant chemotherapy treatment (Tx) in early non-small cell lung cancer (eNSCLC), a high proportion of patients subsequently relapse. This study evaluated real-world Tx patterns, time from surgery to adjuvant Tx initiation and associated overall survival (OS) among eNSCLC resected patients.

1152P Real-world outcomes in resected stage IB-IIIA EGFR mutated NSCLC in Canada: Analysis from the POTENT study

Among patient (pts) who have advanced NSCLC with EGFR driver mutations (EGFRm), most benefit from EGFR tyrosine kinase inhibitors (TKIs). The ADAURA trial showed significant improvement in disease-free survival (DFS) with the addition of the EGFR TKI, osimertinib, in resected early stage (IB-IIIA) EGFRm NSCLC pts. The objective of the POTENT study was to estimate EGFRm prevalence and assess outcomes in resected early stage EGFRm NSCLC in real-world setting in Canada.

Effects of LncRNA MEG3 on immunity and autophagy of non-small cell lung carcinoma through IDO signaling pathway

BackgroundThe study was done to investigate the effect of LncRNA MEG3 on the immunity and autophagy of non-small cell lung carcinoma through the IDO signaling pathway.MethodsA total of 78 cases of early NSCLC patients (research group; RG) and 69 cases of health controls (control group; CG) during the same time were included. The contents of LncRNA MEG3 and miR-543 in peripheral blood and tissues and their diagnostic values for NSCLC were detected. The relationship between LncRNA MEG3 and miR-543 and their posttreatment contents and influence on the prognosis of NSCLC patients were tested. The expression of LncRNA MEG3, miR-543, and IDO (IDO1, IDO2, and TDO proteins) in the lung tissue of rats and the immune function in the CG and the RG were detected. The effects of LncRNA MEG3 and miR-543 on the biological behavior of NSCLC cells were determined. The role of LncRNA MEG3, miR-543, and IDO in NSCLC was verified.ResultsLncRNA MEG3 was low in peripheral blood and tissues, while miR-543 was high (P < 0.05); both had good diagnostic values for NSCLC (P < 0.05). LncRNA MEG3 had a negative correlation with miR-543 (P < 0.05) and influenced the prognosis of NSCLC patients (P < 0.05). LncRNA MEG3 in the lung tissue of rats using IDO inhibitor was elevated compared with that of lung carcinoma model rats (P < 0.05). The level of miR-543 was declined compared with that of lung carcinoma model rats (P < 0.05). The levels of IDO1, IDO2, and TDO proteins were evidently declined compared with those of lung carcinoma model rats (P < 0.05). Compared with lung carcinoma model rats, CD3+, CD4+, and CD4+/CD8+ of IDO inhibitor rats were elevated, while CD8+ was declined (P < 0.05). Cell proliferation and invasion ability and IDO1, IDO2, TDO, Beclin-1, and LC3-II proteins were declined in the sh-LncRNA MEG3 group (P < 0.05), while those in the mimics-miR-543 group were evidently elevated (P < 0.05). However, the double luciferase activity detection and RIP experiment confirmed that there was targeted regulation among them (P < 0.05).ConclusionMEG3 has low expression in NSCLC and affects the immunity and autophagy of NSCLC cells via regulating the miR-543/IDO signaling pathway, which is effective for the treatment of NSCLC.

The Potential Use of Dynamics Changes of ctDNA and cfDNA in the Perioperative Period to Predict the Recurrence Risk in Early NSCLC.

BackgroundPostoperative circulation tumor DNA (ctDNA) is a promising method to predict the risk of recurrence. However, the amount of ctDNA in patients with early NSCLC is too small. Cell damages caused during the intraoperative period leads to a significant increase in cell free DNA (cfDNA). Whether cfDNA content is restored to the preoperative level within a short time after surgery may indicate the degree of surgical trauma. In this study, dynamic changes of cfDNA combined with ctDNA in the perioperative period of NSCLC were used to explore the possibility of them as a biomarker to indicate the risk of recurrence.MethodsNSCLC patients who planned to undergo radical resection were investigated. 10ml of peripheral blood was collected before, during and 7 days after surgery. DNA concentration was measured, and a 23-gene NGS panel was performed to detect gene mutations. All the patients would be followed-up for at least 18 months.ResultsA total of 7 patients were sampled. The amount of cfDNA before surgery was 36.6 ± 14.7ng, and increased to 127.2 ± 52.2ng during surgery. 7 days after surgery, it dropped to 45.23 ± 9.41ng in 3 patients and rose to 173.7 ± 80.80ng in the remaining 4. Only 1 patient was ctDNA positive after surgery, with decreasing cfDNA, and he was the only one that relapsed and died within 18 months.ConclusionThe use of ctDNA to predict the risk of postoperative recurrence of NSCLC is a very valuable method, and it may be more reliable if combined with the dynamic changes of cfDNA. The amounts of cfDNA are raised by the operation, but will be polarized after surgery in 7 days. Postoperative NSCLC patients with positive ctDNA and reduced cfDNA have a higher risk of recurrence.

The Ability of Metabolomics to Discriminate Non-Small-Cell Lung Cancer Subtypes Depends on the Stage of the Disease and the Type of Material Studied

Simple SummaryThe most commonly diagnosed lung cancer is non-small-cell lung cancer (NSCLC). In contrast, the most frequent subtypes of NSCLC, accounting for 80% of cases, are ADC and SCC. Nevertheless, subtype identification is based on the diagnosis of characteristic gene mutations occurring in each subtype. The aim of the study was the metabolomics analysis of the early stage of NSCLC and the determination of new biochemical pathways differentiating the subtypes. Our studies demonstrated that there are new potential significant changes in the biochemical pathways involved in N-acylethanolamine (NAE) biosynthesis that distinguish early-stage SCC from ADC. Moreover, the analysis of the plasma of patients with COPD and NSCLC allows the exclusion of metabolites related to inflammation in the lungs and the identification of compounds characteristic of cancer. Our research indicates new pathways that have not been explored in NSCLC so far, which may have diagnostic, prognostic, and therapeutic potential.Identification of the NSCLC subtype at an early stage is still quite sophisticated. Metabolomics analysis of tissue and plasma of NSCLC patients may indicate new, and yet unknown, metabolic pathways active in the NSCLC. Our research characterized the metabolomics profile of tissue and plasma of patients with early and advanced NSCLC stage. Samples were subjected to thorough metabolomics analyses using liquid chromatography-mass spectrometry (LC-MS) technique. Tissue and/or plasma samples from 137 NSCLC patients were analyzed. Based on the early stage tissue analysis, more than 200 metabolites differentiating adenocarcinoma (ADC) and squamous cell lung carcinoma (SCC) subtypes as well as normal tissue, were identified. Most of the identified metabolites were amino acids, fatty acids, carnitines, lysoglycerophospholipids, sphingomyelins, plasmalogens and glycerophospholipids. Moreover, metabolites related to N-acyl ethanolamine (NAE) biosynthesis, namely glycerophospho (N-acyl) ethanolamines (GP-NAE), which discriminated early-stage SCC from ADC, have also been identified. On the other hand, the analysis of plasma of chronic obstructive pulmonary disease (COPD) and NSCLC patients allowed exclusion of the metabolites related to the inflammatory state in lungs and the identification of compounds (lysoglycerophospholipids, glycerophospholipids and sphingomyelins) truly characteristic to cancer. Our results, among already known, showed novel, thus far not described, metabolites discriminating NSCLC subtypes, especially in the early stage of cancer. Moreover, the presented results also indicated the activity of new metabolic pathways in NSCLC. Further investigations on the role of NAE biosynthesis pathways in the early stage of NSCLC may reveal new prognostic and diagnostic targets.

Circulating genetically abnormal cells combined with artificial intelligence for accurate and non-invasive early detection on NSCLC.

3056 Background: Non-small-cell carcinoma (NCSLC) is the most common type of early lung cancer. Early detection of NSCLC is still a diagnostic challenge. Current clinical management of patients with pulmonary nodule is inefficient and may lead to misclassification, thus increasing healthcare expenses. Further, a few previous studies showed liquid biopsy and artificial intelligence (AI) platform on computed tomography (CT) imaging contributes to early NSCLC detection. Still, there is something lacking in a precise and authorized lung nodule classifier to minimize discomfort of patients. This study aims to evaluate the possibility and effectiveness of combining circulating genetically abnormal cells (CACs) with an AI platform on CT imaging to improve the diagnostic route for NSCLC. Methods: A prospective cohort of 101 in-patients was enrolled from Sep. 1, 2020 to Jan. 15, 2021, with non-calcified pulmonary nodules, ranging from 0.5 to 3 cm in diameter, indicated by CT. The participants' pulmonary nodules will be assessed by two evaluation tools: CAC detection on full blood and AI platform on CT imaging. The diagnostic performances of the two tools were evaluated in a blinded validation study respectively and combined in an open-label retrospective analysis. Results: 68 of enrolled patients were confirmed as NSCLC by pathology. The diagnostic performance of CACs for NSCLC detection was 80.9% for sensitivity and 87.3% for positive predictive value (PPV) while overall accuracy reaches 79.2%. AI platform showed a slight disadvantage as 78.6% for PPV and 73.5% for accuracy. 9 false-negative patients on CAC results could be reversed with a combination of AI platform on CT imaging, while sensitivity rises to 94.1%. However, of 33 benign nodules patients, 8 wrong diagnoses by CAC detection could decrease to 2 when combined with the results from the AI platform, which may avoid unnecessary biopsies. Conclusions: Coupling CAC with an AI platform on CT imaging could be a useful strategy to improve the diagnostic route for NSCLC and avoid unnecessary biopsies.[Table: see text]

Evaluation of Monocarboxylate Transporter 4 (MCT4) Expression and Its Prognostic Significance in Circulating Tumor Cells From Patients With Early Stage Non-Small-Cell Lung Cancer.

Purpose: Monocarboxylate transporter 4 (MCT4) can influence the amount of lactate in the tumor microenvironment and further control cancer cell proliferation, migration, and angiogenesis. We investigated for the first time the expression of MCT4 in circulating tumor cells (CTCs) derived from early stage Non-Small Cell Lung Cancer patients (NSCLC) and whether this is associated with clinical outcome.Experimental Design: A highly sensitive RT-qPCR assay for quantification of MCT4 transcripts was developed and validated and applied to study MCT4 expression in CTC isolated through the Parsortix size-dependent microfluidic device from 53 and 9 peripheral blood (PB) samples of NSCLC patients at baseline (pre-surgery) and at relapse, respectively, as well as the “background noise” was evaluated using peripheral blood samples from 10 healthy donors (HD) in exactly the same way as patients.Results: MCT4 was differentially expressed between HD and NSCLC patients. Overexpression of MCT4 was detected in 14/53 (26.4%) and 3/9 (33.3%) patients at baseline and at progression disease (PD), respectively. The expression levels of MCT4 was found to increase in CTCs at the time of relapse. Kaplan-Meier analysis showed that the overexpression of MCT4 was significantly (P = 0.045) associated with progression-free survival (median: 12.5 months, range 5–31 months).Conclusion: MCT4 overexpression was observed at a high frequency in CTCs from early NSCLC patients supporting its role in metastatic process. MCT4 investigated as clinically relevant tumor biomarker characterizing tumor aggressiveness and its potential value as target for cancer therapy. We are totally convinced that MCT4 overexpression in CTCs merits further evaluation as a non-invasive circulating tumor biomarker in a large and well-defined cohort of patients with NSCLC.

OA06.05 Molecular and Clinical Features Associated with Relapse in Early Stage EGFR-Mutated NSCLC: A Single Institution Knowledge Bank

OA06.05 Molecular and Clinical Features Associated with Relapse in Early Stage EGFR-Mutated NSCLC: A Single Institution Knowledge Bank

P34.09 The Dynamic Changes of ctDNA and cfDNA in the Perioperative Period of Early NSCLC have the Potential to Predict the Risk of Recurrence

P34.09 The Dynamic Changes of ctDNA and cfDNA in the Perioperative Period of Early NSCLC have the Potential to Predict the Risk of Recurrence

Estimating the Impact of Extended Delay to Surgery for Stage I Non-small-cell Lung Cancer on Survival.

The purpose of this study is to evaluate the impact of extended delay to surgery for stage I NSCLC. During the COVID-19 pandemic, patients with NSCLC may experience delays in care, and some national guidelines recommend delays in surgery by >3 months for early NSCLC. Using data from the National Lung Screening Trial, a multi-center randomized trial, and the National Cancer Data Base, a multi-institutional oncology registry, the impact of "early" versus "delayed" surgery (surgery received 0-30 vs 90-120 days after diagnosis) for stage I lung adenocarcinoma and squamous cell carcinoma (SCC) was assessed using multivariable Cox regression analysis with penalized smoothing spline functions and propensity score-matched analyses. In Cox regression analysis of the National Lung Screening Trial (n = 452) and National Cancer Data Base (n = 80,086) cohorts, an increase in the hazard ratio was seen the longer surgery was delayed. In propensity score-matched analysis, no significant differences in survival were found between early and delayed surgery for stage IA1 adenocarcinoma and IA1-IA3 SCC (all P > 0.13). For stage IA2-IB adenocarcinoma and IB SCC, delayed surgery was associated with worse survival (all P < 0.004). The mortality risk associated with an extended delay to surgery differs across patient subgroups, and difficult decisions to delay care during the COVID-19 pandemic should take substage and histologic subtype into consideration.

The dawn of a new era, adjuvant EGFR inhibition in resected non-small cell lung cancer.

Background:Adjuvant platinum-based chemotherapy is standard of care for patients with resected stage IIA/B or IIIA NSCLC. Overall survival is suboptimal due to the high metastatic potential of early-stage NSCLC and there is substantial clinical need for additional efficacious adjuvant treatment options.Methods:PubMed (all time to 4 February 2021) and related conference databases were searched using the key search terms ‘NSCLC’ AND ‘Adjuvant’ AND ‘EGFR inhibitor’ OR respective aliases.Results:The literature search identified five adjuvant phase III trials of EGFR inhibitors in early NSCLC. The earlier BR19 and RADIANT trials failed to demonstrate statistically significant improvements in either OS or DFS for gefitinib and erlotinib, respectively, compared with placebo in patients with EGFR mutation-unselected NSCLC. Three subsequent phase III trials, ADAURA, CTONG1104, and IMPACT, were conducted in EGFR-mutant NSCLC. IMPACT showed no statistically significant DFS benefit for adjuvant gefitinib, and although CTONG1104 did report improved DFS for gefitinib (HR = 0.56, p = 0.001), this benefit was not enduring, resulting in comparable 5-year DFS rates. Statistically significant and clinically meaningful DFS benefits were observed in ADAURA for osimertinib compared with placebo in patients with stage IB-IIIA and II-IIIA disease (7th Edition Staging), and these benefits, coupled with a meaningful improvement in 2-year CNS DFS and favorable HRQoL, make osimertinib an important new treatment option for the adjuvant treatment of EGFR exon 19 deletion or exon 21 L858R-mutated stage II-IIIA NSCLC (UICC/AJCC 8th Edition Staging), with final mature OS data eagerly awaited.Conclusion:Adjuvant osimertinib used alone or following platinum-based chemotherapy is now recommended in patients with stage II-IIIA EGFR-mutated NSCLC.