NSCLC Lung Research Articles

Brief Report: Real-World Treatment Patterns and Clinical Outcomes for Patients With Advanced ALK-Rearranged NSCLC in British Columbia

IntroductionEML4-ALK rearrangements represent an oncogenic driver alteration in 5% of NSCLC cases. We aim to better understand real-world treatment patterns and outcomes of ALK fusion-positive (ALK+) patients with advanced-stage NSCLC. MethodsWe performed a retrospective population-based chart review of ALK+ patients with locally advanced or metastatic NSCLC in British Columbia (BC), Canada. Patients diagnosed from January 2014 to May 2023 were identified through the BC Cancer Genetics Laboratory database, and data were collected up to December 2023. ResultsA total of 216 patients with stage IIIB/IV ALK+ lung NSCLC were identified. Median age was 60 (range: 24–91) years, 151 (68.9%) had never smoked, and 95 (43.9%) were Asian. The median overall survival was 49.4 months with median follow-up time of 55.4 months.Most of the cohort (n = 198, 91.7%) received palliative systemic therapy, all of which included at least one ALK tyrosine kinase inhibitor (TKI). The most common first-line regimen was alectinib (n = 97, 49.0%) followed by crizotinib (n = 84, 42.4%); only four and one patient received lorlatinib and brigatinib first line, respectively. Alectinib was frequently prescribed overall, with 80.3% of patients receiving it in any treatment line. Time to treatment discontinuation was significantly longer on first-line alectinib at 22.9 months as compared with 10.9 months for crizotinib. ConclusionsPatients with ALK+ advanced NSCLC in BC have durable responses to ALK TKIs. Despite approval of all ALK TKIs for first-line use since 2021, alectinib is largely the favored agent in BC. Further real-world investigations can refine treatment strategies and shape policies around ALK TKIs for patients with ALK+ NSCLC.

Abstract LB041: Exploiting a multi-center pre-clinical mouse PDX mini trial to identify new clinical opportunities for protein-drug conjugates (PDCs) targeting ROR1

Abstract The oncofetal cell surface receptor tyrosine kinase ROR1, is expressed on a broad range of solid tumors and hematological malignancies but is largely absent from normal adult tissue. Increased ROR1 expression correlates with poor clinical outcome in certain cancer indications, consistent with its functional role in tumorigenesis, increased metastatic potential and drug resistance. The oncofetal expression pattern of ROR1, coupled with its role in cancer pathology and therapy resistance, and its scaffolding function in caveolae, makes it a highly attractive target for a protein-drug conjugate (PDC) approach. A number of ROR1-targeting ADC and PDC agents are in clinical and pre-clinical development. Understanding the molecular determinants that drive the efficacy of these agents, may open-up patient selection strategies to improve clinical outcomes for ROR1-targeted ADC/PDC therapy. We utilized a small-domain protein-drug-conjugate platform to develop a PDC Candidate Drug (ADP-c389) which produced complete and sustained tumor regressions in patient-derived xenograft (PDX) models of triple negative breast cancer (TNBC) and had an excellent therapeutic index in mice and NHPs. To further inform our clinical planning and assess the broader clinical opportunity afforded by this agent, ADP-c389 was evaluated in a multi-center, multi-indication, 30-PDX mouse mini trial covering 5 different solid tumor indications (lung, ovarian, endometrial, esophageal, gastric). Covariates of target expression, site, model, mouse strain and treatment effect were analysed longitudinally and a multi-metric (TGI, AUC, Best Average Response (BAR), mRECIST) effects analysis undertaken to evaluate response. Efficacy was observed in each of the cancer indications tested, with 77% of models showing an anti-tumor response. Furthermore, the results in NSCLC lung and ovarian PDX models indicated that these are compelling additional cancer types in which to position ADP-c389 clinically. Whilst all responders are ROR1 positive, ROR1 expression itself is necessary but not sufficient to predict the degree of response. Linear Mixed Effect Model (LMM) and multi-omics (RNA-Seq and Proteomics) analysis of the resulting responder/non-responder cohorts has enabled us to determine markers of sensitivity to ADP-c389. In summary, ADP-c389 represents a highly differentiated product for the treatment of a variety of solid tumors. The learnings from this mouse mini trial are also being applied to bi-specific ROR1-based PDCs. Citation Format: Aaron N. Cranston, Mark Wappett, Estelle G. McLean, Chiara Saladino, Aidan McCann, Wei-Wei Kung, Jennifer Thom, Paul Trumper, Andy Porter, Caroline Barelle, Tim Harrison, Graham Cotton. Exploiting a multi-center pre-clinical mouse PDX mini trial to identify new clinical opportunities for protein-drug conjugates (PDCs) targeting ROR1 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB041.

Abstract LB451: Targeting oncogenic transcription and signaling crosstalk fueling drug resistance in lung cancer

Abstract Lung cancer is the leading cause of all cancer-related mortality worldwide. The RAS-RAF-MEK-ERK (RAS-MAPK) signaling pathway is critical for maintaining cell survival and proliferation. Somatic mutations in the RAS or RAF genes are associated with frequent hyper-activation of RAS-MAPK pathway in non-small cell lung cancer or NSCLC. While direct inhibitors of KRAS G12C are emerging with promising efficacy, resistance to these agents as well as to inhibitors of RAF and MEK remains an obstacle to long-term patient survival. Therefore, it is essential to understand how drug resistance emerges in lung cancer and to identify bypass survival pathways or compensatory mechanisms that limit the response to RAS-MAPK targeted therapies in lung cancer. Emerging literature indicates a critical role of bromodomain and extra-terminal domain (BET) family of bromodomain proteins (BRD4, BRD3, BRD2) in various human malignancies and provides the rational for targeting BET proteins as a strategy for the development of new anticancer drugs. Using combinatorial drug screens in a panel of NSCLC cell lines, we found that BET proteins act in parallel to the RAS-MAPK pathway to promote drug resistance in lung cancer. Combination of BET and RAS-MAPK inhibitors caused pronounced cell death and potent tumor regression/stasis in several KRAS or BRAF mutant models of NSCLC with synergistic apoptosis induction and downregulation of MYC, a transcriptional target of BET proteins. However, concurrent loss of the tumor suppressor STK11 (aka LKB1) in NSCLC cells induced activation of the Hippo pathway effector and transcriptional co-activator, YAP and conferred resistance to the BET and RAS-MAPK inhibitors combination in NSCLC cells and tumors.These findings suggest an unprecedented functional interplay between BET chromatin regulators, Hippo-YAP and RAS-MAPK signaling in lung cancer and therapy resistance. Further, this study identified STK11 as a modifier of sensitivity to the BET and RAS-MAPK inhibitors combination in NSCLC cells and tumors. Citation Format: Nilanjana Chatterjee, Victor Olivas, Wei Wu, Tracy Tang, Ben Powell, Trever Bivona. Targeting oncogenic transcription and signaling crosstalk fueling drug resistance in lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB451.

131 Early stage lung cancer outcomes – a 10 year review of surgery and radiotherapy in patients with performance status 0-1 and Stage I and II NSCLC lung cancer

131 Early stage lung cancer outcomes – a 10 year review of surgery and radiotherapy in patients with performance status 0-1 and Stage I and II NSCLC lung cancer

Abstract 4663: Establishing the role of PRMT5 in lung cancer tumorigenicity and modulation of expression in smokers

Abstract Studies show that PRMT5 (protein arginine methyl transferase 5) is responsible for increased tumorigenicity by activation of the PI3K/Akt signaling pathway promoting increased cancer cell proliferation. However, the role of PRMT5 in modulating EGFR TKI resistance is minimally studied. We hypothesize that over-expression of PRMT5 could promote tumorigenesis and TKI resistance by activating PI3K-Akt-mTOR signaling pathways. Hence, modulating this key biomarker may help reduce tumorigenicity and overcome TKI resistance. We performed qPCR to study the expression of PRMT5 in normal lung cells and NSCLC cell lines. We also compared the expression of these biomarkers in erlotinib resistant (ER) and Osimertinib resistant (OR) cells using Western blotting. PRMT5 was inhibited using GSK591 (PRMT5i) to evaluate its sensitivity to EGFR TKIs (ER and OR). PRMT5 expression in normal lung cells and NSCLC cells treated with Cigarette smoke extract (CSE) were also studied and correlated with immunostaining results from smoker and non-smoker lung tumor tissue samples. Changes in PRMT5 expression were analyzed in WT-EGFR lung cancer cell lines (H358, H2170), mutant EGFR lung cancer cell lines (H3255, H1975, PC9) and normal lung fibroblast cells (HLF). PRMT5 expression was upregulated by 1.6-2.1 fold in HLF, H2170 and H358 cells after 1 week of treatment with CSE. CSE treatment also upregulated expression of inflammatory cytokines (IL-1β, IL-8 and TNF-α) in H358 cells by 1.6-7 fold as analyzed by qPCR. PRMT5 expression was upregulated in EGFR-TKI resistant cell lines, by 1.5-1.9 fold in PC9ER, PC9OR and H2170ER cells, compared to parental cells. Similar results were found using qPCR, with 1.6-2.3 fold increase in PRMT5 mRNA expression in H2170OR, PC9ER/OR and H3255OR cells compared to parental cells. An MTT assay was done to assess percentage viability of cells after treatment of PRMT5i. While 2μM PRMT5i treatment of PC9OR cells decreased cell viability by 42%, an inhibitory effect that was more than additive was seen with a combination of 2μM of PRMT5i and 21nM of OR. Similar results were also observed in H2170ER cells. Migratory properties of OR resistant cells, were studied by wound healing assays. Percentage wound area in PRMT5i treated PC9OR cells was 29.3% as compared to 6.1% and 10.5% in diluent and OR treated cells respectively after 48 hrs. Combination treatment of PRMT5i and OR further inhibited cell migration with higher wound area of 41.7%. Immunostaining of lung tumor sections from smokers and non-smokers showed high expression of PRMT5 localized in the cytoplasm and nucleus. Microscopic analysis of 20 tumor sections from smokers showed higher expression of PRMT5 (p<0.05) compared to non-smokers. We can conclude that PRMT5 is upregulated in TKI resistant cells causing tumorigenesis. Modulation of PRMT5 can prove to be groundbreaking and revolutionary, as it may increase the efficacy of EGFR TKIs. Citation Format: Syed N. Ali, Meet Patel, Bamby Dieng, Cody Lund, Neelu Puri. Establishing the role of PRMT5 in lung cancer tumorigenicity and modulation of expression in smokers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4663.

Trilobolide-6-O-isobutyrate from Sphagneticola trilobata acts by inducing oxidative stress, metabolic changes and apoptosis-like processes by caspase 3/7 activation of human lung cancer cell lines

BackgroundLung cancer, a chronic and heterogeneous disease, is the leading cause of cancer-related death on a global scale. Presently, despite a variety of available treatments, their effectiveness is limited, often resulting in considerable toxicity and adverse effects. Additionally, the development of chemoresistance in cancer cells poses a challenge. Trilobolide-6-O-isobutyrate (TBB), a natural sesquiterpene lactone extracted from Sphagneticola trilobata, has exhibited antitumor effects. Its pharmacological properties in NSCLC lung cancer, however, have not been explored. PurposeThis study evaluated the impact of TBB on the A549 and NCI-H460 tumor cell lines in vitro, examining its antiproliferative properties and initial mechanisms of cell death. MethodsTBB, obtained at 98 % purity from S. trilobata leaves, was characterized using chromatographic techniques. Subsequently, its impact on inhibiting tumor cell proliferation in vitro, TBB-induced cytotoxicity in LLC-MK2, THP-1, AMJ2-C11 cells, as well as its effects on sheep erythrocytes, and the underlying mechanisms of cell death, were assessed. ResultsIn silico predictions have shown promising drug-likeness potential for TBB, indicating high oral bioavailability and intestinal absorption. Treatment of A549 and NCI-H460 human tumor cells with TBB demonstrated a direct impact, inducing significant morphological and structural alterations. TBB also reduced migratory capacity without causing toxicity at lower concentrations to LLC-MK2, THP-1 and AMJ2-C11 cell lines. This antiproliferative effect correlated with elevated oxidative stress, characterized by increased levels of ROS, superoxide anion radicals and NO, accompanied by a decrease in antioxidant markers: SOD and GSH. TBB-stress-induced led to changes in cell metabolism, fostering the accumulation of lipid droplets and autophagic vacuoles. Stress also resulted in compromised mitochondrial integrity, a crucial aspect of cellular function. Additionally, TBB prompted apoptosis-like cell death through activation of caspase 3/7 stressors. ConclusionThese findings underscore the potential of TBB as a promising candidate for future studies and suggest its viability as an additional component in the development of novel anticancer drugs prototypes.

Immunological signatures from irradiated cancer-associated fibroblasts.

Cancer-associated fibroblasts (CAFs) are abundant and influential elements of the tumor microenvironment (TME), giving support to tumor development in multiple ways. Among other mechanisms, CAFs are important regulators of immunological processes occurring in tumors. However, CAF-mediated tumor immunomodulation in the context of radiotherapy remains poorly understood. In this study, we explore effects of radiation on CAF-derived immunoregulatory signals to the TME. Primary CAF cultures were established from freshly collected human NSCLC lung tumors. CAFs were exposed to single-high or fractionated radiation regimens (1x18Gy or 3x6Gy), and the expression of different immunoregulatory cell-associated and secreted signaling molecules was analyzed 48h and 6 days after initiation of treatment. Analyses included quantitative measurements of released damage-associated molecular patterns (DAMPs), interferon (IFN) type I responses, expression of immune regulatory receptors, and secretion of soluble cytokines, chemokines, and growth factors. CAFs are able to survive ablative radiation regimens, however they enter into a stage of premature cell senescence. Our data show that CAFs avoid apoptosis and do not contribute by release of DAMPs or IFN-I secretion to radiation-mediated tumor immunoregulation. Furthermore, the secretion of relevant immunoregulatory cytokines and growth factors including TGF-β, IL-6, IL-10, TNFα, IL-1β, VEGF, CXCL12, and CXCL10 remain comparable between non-irradiated and radiation-induced senescent CAFs. Importantly, radiation exposure modifies the cell surface expression of some key immunoregulatory receptors, including upregulation of CD73 and CD276. Our data suggest that CAFs do not participate in the release of danger signals or IFN-I secretion following radiotherapy. The immune phenotype of CAFs and radiation-induced senescent CAFs is similar, however, the observed elevation of some cell surface immunological receptors on irradiated CAFs could contribute to the establishment of an enhanced immunosuppressive TME after radiotherapy.

Utilisation of radiotherapy in lung cancer: A scoping narrative literature review with a focus on the introduction of evidence-based therapeutic approaches in Europe

Background and purposeThe aim of this study was to review the published studies on the utilisation of radiotherapy in lung cancer (both small and non-small cell lung cancer, SCLC and NSCLC) patients in European countries with a population-based perspective. Material and methodsA literature search since January 2000 until December 2022 was carried out. Only English-published papers were included, and only European data was considered. PRISMA guidelines were followed. A scoping narrative review was undertaken due to the hetereogeneity of the published papers. Results38 papers were included in the analysis, with the majority from the Netherlands (52.6%) and the UK (18.4%). Large variability is observed in the reported radiotherapy utilisation, around 40% for NSCLC in general and between 26 and 42% in stage I NSCLC. Stereotactic body radiotherapy (SBRT) shows a wide range of utilisation across countries and over time, from 8 to 63%. Similary, in stage III lung cancer, chemoradiotherapy (CRT) utilisation varied considerably (11–70%). Eleven studies compared radiotherapy utilisation between older and younger age-groups, showing that younger patients receive more CRT, while the opposite applies for SBRT. An widespreadlack of data on relevant covariates such as comorbidty and health-services related variables is observed. ConclusionThe actual utilisation of radiotherapy for lung cancer reported in patterns-of-care studies (POCs) is notably lower than the evidence-based optimal utilisation. Important variability is observed by country, time period, stage at diagnosis and age. A wider use of POCs should be promoted to improve our knowledge on the actual application of evidence-based treatment recommendations.

Adaptive Dose-Staged Stereotactic Ablative Body Radiotherapy for Treatment of Large Central NSCLC Lung Tumors: A Dosimetric Simulation Study

Adaptive dose-staged Stereotactic Radiosurgery (SRS) treatment of cranial AVM and personalized ultrafractionated stereotactic ablative radiotherapy (PULSAR) proposed by Timmerman et al. for lung cancer has been shown to be an effective technique with lower toxicities in the management of large lesions. The PULSAR technique requires periodic functional PET imaging or tumor biopsy more than one week apart post stereotactic ablative body radiotherapy (SABR) PULSE to utilize the tumor biological response feedback to delineate the residual active disease for subsequent (SABR) PULSES' adaptive treatment planning. The purpose of this study is to explore dosimetrically the benefit of SABR PULSES for the treatment of large central lungs tumors. A retrospective simulation study of five anonymized patients with large NSCLC was performed. Tumors were located centrally in left (N = 3) and right (N = 2) lungs. The PTVs generated by 5mm symmetric margin to the ITV, the ITV and PTV volumes were 30.0±21.4cc (10.6-64.5cc) and 65.4±35.2cc (30.7-121.0cc), respectively. Depending on the total PTV volume, 4 other adaptive PTVs were simulated by generating a symmetric reduction of the PTV volumes by 2 or 3mm assuming given enough time shrinking the original volume after each PULSE due to biological response during the time between the initial and subsequent SABR PULSES. The organs-at-risk (OARs) were contoured and 3 VMAT arcs plans were generated and optimized for each PTV with the same VMAT objective functions. The original PTV plan with 50 Gy in 5 consecutive fractions was compared with the sum of the 5 PULSES in 10 Gy per PULSE with adaptive volumes. A statistical analysis and a paired t-test of the 50 Gy plan in 5 consecutive fractions were compared with the 5 PULSES summed dose for the ITV, PTV, and the OARs. The t-test showed the 5 PULSES plans significantly lowered the doses to the ipsilateral, and contralateral lungs and heart when compared to 5 consecutive 10 Gy/fraction plans (p-Values, 0.031, 0.01, 0.02, respectively). The 11 Gy ipsilateral lung volume, a precursor for developing normal lung tissue fibrosis about one-year post SABR was significantly lower for the 5 PULSES (136±44cc Vs. 241±83cc) (p-Value, 0.01). The mean and maximum dose to the original PTV was significantly lower in 5 PULSES technique (p-Value, 0.0001, 0.046). The dose to the spinal canal was not statistically different between the two techniques (p-Value, 0.12). The current management of large central lung tumors is conventional fractionation with chemotherapy or delivering lower fractional SABR dose to meet the OAR dose constraints that may hinder the successful radioablation and local control. The PULSAR treatments using SABR dosimetrically provides significant sparing of normal tissue. Dose escalation for larger central lung tumors may be possible using this technique for effective local control and better overall survivorship.

Diagnostic Performance of Dynamic Whole-Body Patlak [18F]FDG-PET/CT in Patients with Indeterminate Lung Lesions and Lymph Nodes.

Static [18F]FDG-PET/CT is the imaging method of choice for the evaluation of indeterminate lung lesions and NSCLC staging; however, histological confirmation of PET-positive lesions is needed in most cases due to its limited specificity. Therefore, we aimed to evaluate the diagnostic performance of additional dynamic whole-body PET. A total of 34 consecutive patients with indeterminate pulmonary lesions were enrolled in this prospective trial. All patients underwent static (60 min p.i.) and dynamic (0-60 min p.i.) whole-body [18F]FDG-PET/CT (300 MBq) using the multi-bed-multi-timepoint technique (Siemens mCT FlowMotion). Histology and follow-up served as ground truth. Kinetic modeling factors were calculated using a two-compartment linear Patlak model (FDG influx rate constant = Ki, metabolic rate = MR-FDG, distribution volume = DV-FDG) and compared to SUV using ROC analysis. MR-FDGmean provided the best discriminatory power between benign and malignant lung lesions with an AUC of 0.887. The AUC of DV-FDGmean (0.818) and SUVmean (0.827) was non-significantly lower. For LNM, the AUCs for MR-FDGmean (0.987) and SUVmean (0.993) were comparable. Moreover, the DV-FDGmean in liver metastases was three times higher than in bone or lung metastases. Metabolic rate quantification was shown to be a reliable method to detect malignant lung tumors, LNM, and distant metastases at least as accurately as the established SUV or dual-time-point PET scans.

Phase 1/2 study of tusamitamab ravtansine in patients with advanced solid tumors: Pooled safety analysis of corneal adverse events.

e15003 Background: Tusamitamab ravtansine (tusa rav) is a novel antibody-drug conjugate (ADC) targeted to carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) and delivering DM4, a cytotoxic maytansinoid. CEACAM5 is highly expressed in several tumor types, including nonsquamous non-small cell lung cancer (NSQ NSCLC). An open-label, Phase 1/2, dose-escalation/expansion study (NCT02187848) in patients with advanced solid tumors found the maximum tolerated dose of tusa rav to be 100 mg/m2 every 2 weeks (Q2W) with a dose-limiting toxicity of microcystic keratopathy. Tusa rav had a favorable safety profile and, in patients with NSQ NSCLC with high CEACAM5 expression, promising antitumor activity. Methods: Here we evaluate pooled corneal safety results in patients (n = 186) who received tusa rav 100 mg/m2 Q2W, including cohorts of patients with NSQ NSCLC, colorectal, gastric, or small cell lung cancers. Patients who had history of corneal disorders, contraindications to ocular prophylactic drops, or were unable to stop contact lens use for the study were ineligible. Artificial tear use was encouraged during the study. Results: In patients treated with tusa rav 100 mg/m² (median treatment duration 8.7 weeks [range 2–154]), corneal treatment-emergent adverse events (TEAEs) were reported in 56/186 (30.1%), with the worst grade being Grade 1 as asymptomatic (n = 7), Grade 2 (n = 33), and Grade 3 (n = 16). No patients had Grade 4 (perforation or blindness) or serious corneal adverse events. The most frequent corneal TEAEs were keratitis and keratopathy in 22% and 11.8% (Grade 3 in 6.5% and 2.7%) of 186 patients, respectively. Occurrence of Grade ≥2 corneal events was significantly associated with tusa rav exposure in Q2W dosing (including dose-escalation ≤150 mg/m2). Most patients with corneal TEAEs had first occurrence within the first 4 cycles (45/56), including 16 in Cycle 2 and none in Cycle 1. At analysis cut-off, corneal TEAEs had resolved in 40/56 (71.4%) patients. The median recovery time was 20.5 days (range, 8–264). Of the 186 patients, corneal TEAEs led to cycle delay in 15.6%, cycle delay with dose reduction in 7.0%, and no treatment discontinuations. Corneal TEAEs recurred in 19/56 (33.9%) patients with a median time to recurrence of 16 days. Primary prophylaxis (ophthalmic vasoconstrictor, corticosteroid gel, and/or cold masks at infusion) in only the right eye in 107 patients did not show benefit (98% of the 55 events were bilateral), supporting use of secondary prophylaxis only as needed in subsequent patients. Conclusions: Corneal TEAEs observed in the study were nonserious and typically reversible; management with dose modification allowed continuation of treatment. These results support the ongoing clinical development of tusa rav. Further investigation of the mechanisms of corneal TEAEs with ADCs and their management is necessary. Clinical trial information: NCT02187848 .

Abstract 185: Global mapping of pathway modules and phosphorylation networks in PDX and corresponding organoid (PDXO) models treated with targeted therapies

Abstract Introduction: Multi-omics-based strategies in precision medicine, including genomic, transcriptomic and proteomic data, have contributed to the molecular-level characterization of cancers and the identification of novel driver genes, as well as a better comprehension of resistance mechanisms. Patient-derived tumor models, including patient-derived xenograft (PDX) and in vitro 3D organoid counterparts (PDXO), are widely recognized as predictive preclinical cancer models closely recapitulating both tumor complexity and patient response and enabling the study of tumor identity for personalized medicine. Taking advantage of Crown Bioscience large PDX collection, with genomic and phenotypic annotation and pharmacological validation, a series of PDXO models have been established and characterized to be used as scalable and high throughput compatible drug screening platforms. Methods: Drug response in matched PDX and PDXO models were investigated on the functional and systems level through deep whole- and phospho-proteomic analysis. For this purpose, analysis and comparisons were made across dose and time series, the effect of several targeted therapies on protein expression and phosphorylation in both PDX and PDXO tumor models. More specifically, a KRAS inhibitor (AMG510), a BCR-ABL TKI (ponatinib) and an EGFR TKI (afatinib) were tested respectively in a lung NSCLC model carrying KRAS G12C mutation, a colorectal model with RET fusion and a lung NSCLC model with EGFR exon 19 deletion. Results: Based on previous data, a specific relationship between area under the curve (AUC) value of organoid drug dose response and in vivo tumor growth has been observed, irrespective of the drug treatment. To interrogate the pathways involved, both PDX and PDXO models were subjected to deep proteome and phospho-proteome profiling using state-of-the-art mass spectrometry-based workflows. An extensive dataset was generated where 16,797 proteins and 12,578 proteins were robustly quantified in PDX and PDXO models respectively. From the same samples, 35,403 phospho-sites were quantified across all PDX samples while 40,754 phospho-sites were quantified across all PDXO models. These data enabled the validation of known pathways (such as RAF/MEK/ERK, PI3K/AKT) and pinpoint new ones modulated through three small molecule inhibitors each targeting a defined genetic background. Conclusion: The predictivity of organoid cultures was demonstrated to model in vivo drug responses and also to serve as a powerful platform to investigate target identification, mechanism of action and resistance mechanism via functional proteome and phospho-proteome analysis. Citation Format: Martin Mehnert, Xiaoxi Xu, Tobias Treiber, Limei Shang, Leilei Chen, Jessie Wang, Marco Tognetti, Christopher Below, Roland Bruderer, Jakob Vowinckel, Binchen Mao, Wubin Qian, Sheng Guo, Ludovic Bourré, Yuehan Feng. Global mapping of pathway modules and phosphorylation networks in PDX and corresponding organoid (PDXO) models treated with targeted therapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 185.

Driver and actionable mutations in younger patients with lung cancer - are we searching properly?

The authors focused on a group of young lung cancer patients with the aim of better understanding the mechanisms of tumor pathogenesis in these patients and search for potential targetable mutations. We collected retrospective data on patients under 40 years diagnosed with lung cancer (NSCLC or small-cell lung cancer) from 2011-2020 at the Department of Respiratory Diseases, University Hospital Brno, Czech Republic. Tumor tissue of these patients was analysed by next-generation sequencing (NGS, a panel of 550 variants in 19 genes). Demographic characteristics, smoking history, histology, molecular-genetic results and clinical stage of the disesase were recorded in all eligible patients from accessible medical databases. Of 17 identified patients in only 8 cases was successful NGS carried out due to lack of sufficient good quality material in the other cases. The most frequently found molecular genetic changes were EGFR, RICTOR and HER2 amplification and MET and FGFR1 amplification. In addition, we found rare pathogenic variants in BRAF and PIK3CA genes. Actionable variants were detected in 75% patients. We detected very frequent driver and potentially actionable alterations in young patients with lung cancer. This suggests different mechanisms of carcinogenesis in these patients and indicates that they might benefit more from a specific approach than older lung cancer patients.

Feasibility and safety of shortened hypofractionated high-dose palliative lung radiotherapy – A retrospective planning study

ObjectiveAssess the safety and feasibility of shortened hypofractionated high-dose palliative lung radiotherapy in a retrospective planning study. MethodsFifteen late stage (III or IV) NSCLC lung radiotherapy patients previously treated with the standard palliative 36 Gy in 12 fractions (12F) schedule were non-randomly selected to achieve a representative distribution of tumour sizes, volumes, and location. Plans were produced using 30 Gy in 5 fractions (5F) and 6 fractions (6F) using a 6MV FFF co-planar VMAT technique. Plans were optimised to meet dose-constraints for planning target volumes (PTVs) and organs at risk (OARs) with established OAR constraints expressed as biological equivalent doses (BEDs). The potential safety was assessed using these BEDs and also with reductions of 10% (BED-10%) and 20% (BED-20%) to account for a reduction in tolerance doses from the effects of chemotherapy or surgery. ResultsMandatory BED constraints were met for all fifteen 5F and 6F plans; BED-10% constraints were met by all 6F plans and six 5F plans. BED-20% constraints were met by six 6F and three 5F respectively. ConclusionIt is potentially safe and feasible to deliver high-dose palliative radiotherapy for late stage NSCLC using the 5F or 6F regimes described, when planned to comparable OAR BEDs as standard radical techniques. It appears toxicity from these regimes should be within acceptable limits provided the dose-constraints described are met. A Phase II study is required to fully assess safety and feasibility, the outcomes of which could reduce the number of patient hospital visits for radiotherapy, thereby benefiting patients and optimising resource utilisation.

Development of an adenosquamous carcinoma histopathology - selective lung metastasis model.

Preclinical tumor models with native tissue microenvironments provide essential tools to understand how heterogeneous tumor phenotypes relate to drug response. Here we present syngeneic graft models of aggressive, metastasis-prone histopathology-specific NSCLC tumor types driven by KRAS mutation and loss of LKB1 (KL): adenosquamous carcinoma (ASC) and adenocarcinoma (AC). We show that subcutaneous injection of primary KL; ASC cells results in squamous cell carcinoma (SCC) tumors with high levels of stromal infiltrates, lacking the source heterogeneous histotype. Despite forming subcutaneous tumors, intravenously injected KL;AC cells were unable to form lung tumors. In contrast, intravenous injection of KL;ASC cells leads to their lung re-colonization and lesions recapitulating the mixed AC and SCC histopathology, tumor immune suppressive microenvironment and oncogenic signaling profile of source tumors, demonstrating histopathology-selective phenotypic dominance over genetic drivers. Pan-ERBB inhibition increased survival, while selective ERBB1/EGFR inhibition did not, suggesting a role of the ERBB network crosstalk in resistance to ERBB1/EGFR. This immunocompetent NSCLC lung colonization model hence phenocopies key properties of the metastasis-prone ASC histopathology, and serves as a preclinical model to dissect therapy responses and metastasis-associated processes.

Respiratory and Cardiometabolic Comorbidities and Stages I to III NSCLC Survival: A Pooled Analysis From the International Lung Cancer Consortium

IntroductionWe explored the association of respiratory and cardiometabolic comorbidities with NSCLC overall survival (OS) and lung cancer-specific survival (LCSS), by stage, in a large, multicontinent NSCLC pooled data set. MethodsOn the basis of patients pooled from 11 International Lung Cancer Consortium studies with available respiratory and cardiometabolic comorbidity data, adjusted hazard ratios (aHRs) were estimated using Cox models for OS. LCSS was evaluated using competing risk Grey and Fine models and cumulative incidence functions. Logistic regression (adjusted OR [aOR]) was applied to assess factors associated with surgical resection. ResultsOS analyses used patients with NSCLC with respiratory health or cardiometabolic health data (N = 16,354); a subset (n = 11,614) contributed to LCSS analyses. In stages I to IIIA NSCLC, patients with respiratory comorbidities had worse LCCS (stage IA aHR = 1.51, confidence interval [CI]: 1.17–1.95; stages IB–IIIA aHR = 1.20, CI: 1.06–1.036). In contrast, patients with stages I to IIIA NSCLC with cardiometabolic comorbidities had a higher risk of death from competing (non-NSCLC) causes (stage IA aHR = 1.34, CI: 1.12–1.69). The presence of respiratory comorbidities was inversely associated with having surgical resection (stage IA aOR = 0.54, CI: 0.35–0.83; stages IB–IIIA aOR = 0.57, CI: 0.46–0.70). ConclusionsThe presence of either cardiometabolic or respiratory comorbidities is associated with worse OS in stages I to III NSCLC. Patients with respiratory comorbidities were less likely to undergo surgery and had worse LCSS, whereas patients with cardiometabolic comorbidities had a higher risk of death from competing causes. As more treatment options for stages I to III NSCLC are introduced into the practice, accounting for cardiometabolic and respiratory comorbidities becomes essential in trial interpretation and clinical management.

Identification of the effects of COVID-19 on patients with pulmonary fibrosis and lung cancer: a bioinformatics analysis and literature review.

Coronavirus disease 2019 (COVID-19) poses a serious threat to human health and life. The effective prevention and treatment of COVID-19 complications have become crucial to saving patients’ lives. During the phase of mass spread of the epidemic, a large number of patients with pulmonary fibrosis and lung cancers were inevitably infected with the SARS-CoV-2 virus. Lung cancers have the highest tumor morbidity and mortality rates worldwide, and pulmonary fibrosis itself is one of the complications of COVID-19. Idiopathic lung fibrosis (IPF) and various lung cancers (primary and metastatic) become risk factors for complications of COVID-19 and significantly increase mortality in patients. Therefore, we applied bioinformatics and systems biology approaches to identify molecular biomarkers and common pathways in COVID-19, IPF, colorectal cancer (CRC) lung metastasis, SCLC and NSCLC. We identified 79 DEGs between COVID-19, IPF, CRC lung metastasis, SCLC and NSCLC. Meanwhile, based on the transcriptome features of DSigDB and common DEGs, we identified 10 drug candidates. In this study, 79 DEGs are the common core genes of the 5 diseases. The 10 drugs were found to have positive effects in treating COVID-19 and lung cancer, potentially reducing the risk of pulmonary fibrosis.

EP08.02-169 Research of Aumolertinib Combined with Bevacizumab for Advanced NSCLC Lung Cancer with EGFR Sensitive Mutation

Aumolertinib (formerly almonertinib; HS-10296) is a novel third-generation EGFR-TKI with proved efficiency and safety for untreated NSCLC patients with EGFR sensitizing mutations in China. The efficacy of the combination of first-generation EGFR-TKI and bevacizumab was confirmed by NEJ026, JO25567 ARTEMIS studies, but the effect of 3rd generation TKI plus bevacizumab is still under debate. This study was conducted to evaluate aumolertinib plus bevacizumab for untreated NS-NSCLC patients with EGFR sensitizing mutations.

Abstract 5353: PIK3CA and PTEN mutations as drivers of osimertinib resistance in patients with NSCLC

Abstract Osimertinib is a third-generation EGFR-TKI approved for the first-line treatment of EGFR-driven lung adenocarcinomas. High response rates to osimertinib are observed in patients with activating EGFR mutations. However, there is variability in duration of response and patients eventually develop acquired resistance.Preclinical validation of potential acquired resistance mutations identified in relapsed patients treated with osimertinib is a key challenge to develop new strategies to improve outcomes for patients with EGFR mutation positive NSCLC. Tissue and ctDNA NGS analysis from relapsed patients treated first-line with osimertinib in the FLAURA and ORCHARD trials identified PIK3CA gain of function (GOF 11%) and PTEN loss of function (LOF 5%) mutations.To test whether PIK3CA activating mutations can drive resistance to osimertinib we introduced PIK3CA activating variants (PIK3CA-H1047R and PIK3CA-E453K) or knocked-out PTEN in NSCLC lung cancer cell lines harbouring EGFR activating mutations and WT PIK3CA/PTEN using CRISPR/Cas9 technology. Our results show that PIK3CA GOF and PTEN LOF mutations conferred resistance to osimertinib in vitro. Resistance was associated with increased EC50 for osimertinib and diminished apoptotic response in NSCLC PIK3CA GOF and PTEN LOF mutant CRISPR cell lines when compared to parental cells. Protein analysis by western blot also showed an increase in the basal and osimertinib treated levels of pAKT and pS6 in PIK3CA/PTEN CRISPR engineered cell lines, indicating activation of downstream PI3K/AKT and MAPK signalling pathways in the osimertinib-resistant cells. Importantly, our in vitro experiments from multiple cell line models indicated that PIK3CA-mediated resistance to osimertinib could be partially reversed by co-treatment with AKT (capivasertib, AstraZeneca) and PI3K alpha (alpelisib, Novartis) inhibitors; PTEN-mediated resistance could be rescued by co-treatment with capivasertib and PI3K beta (AZD8186, AstraZeneca) inhibitors. We next examined the in vivo efficacy of osimertinib + AKT/PI3K inhibitors therapies in NSCLC xenograft models. Our in vivo analysis show that PIK3CA GOF CRISPR engineered cells displayed diminished response to osimertinib when implanted in mice; importantly, combination with AKT (capivasertib) or PI3K alpha (alpelisib) inhibitors enhanced response on treatment and delayed outgrowth after withdrawal treatment. In addition, we observed that combination treatment with capivasertib induced tumour stasis in a PIK3CA-E454K and two PTENloss PDX models.Altogether our in vitro and in vivo data provide evidence of PIK3CA mutants and PTEN loss-driven mechanisms of resistance to osimertinib and offer possible therapeutic combination strategies for those patients that develop resistance or experience a sub-optimal response to osimertinib through PIK3CA/PTEN mutations Citation Format: Ursula Grazini, Daniel J. O'Neill, Matthew Martin, Chintia Xu, Nicolas Floch, Paul D. Smith, Emanuela Cuomo. PIK3CA and PTEN mutations as drivers of osimertinib resistance in patients with NSCLC [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 5353.

Abstract 3110: Identification of the phosphorylation network in PDX and corresponding organoid (PDXO) models upon targeted therapy treatment using deep phosphoproteomic analysis[MB1

Abstract In precision medicine, genomic, transcriptomic, and proteomic data has contributed to the identification of novel driver genes and the molecular-level characterization of cancers. This data has led to a better understanding of drug modulation and resistance mechanisms. Patient-derived tumor models, including patient-derived xenograft (PDX) and organoid counterparts (PDXO), have been increasingly viewed as predictive preclinical cancer models. These models closely recapitulate tumor complexity, enabling the study of tumor identity for personalized medicine. Leveraging our large PDX collection models which are genomically and phenotypically annotated and validated, we have established and characterized a series of PDXO models to be used as scalable and high throughput compatible drug screening platforms. Here we conducted methodical analysis of drug response in paired PDX and PDXO models. In addition, trough deep whole- and phospho-proteomic analysis, we have analyzed and compared the effect of targeted therapies on protein expression and phosphorylation in both PDX and PDXO tumor models. Indeed, one of the most common post-translational modifications that is involved in cell regulation and intracellular signal transduction is reversible protein phosphorylation catalyzed by protein kinases. For this purpose, we have tested a KRAS inhibitor (AMG510), BCR-ABL TKI (Ponatinib) and EGFR TKI (Afatinib) respectively in lung NSCLC model carrying KRAS G12C mutation, colorectal model with RET fusion and Lung NSCLC model with EGFR exon 19 deletion. According to our historical data, a specific relationship between area under the curve value of organoid drug dose response and in vivo tumor growth has been observed, irrespective of the drug treatment. Furthermore, comparison between PDX and PDXO models deploying quantitative proteomic data enabled deep characterization of both global expression and signaling cascades modulated through small molecule inhibitors. Thus, we demonstrate the predictivity of organoid cultures to not only model in vivo drug responses but also to serve as a powerful platform to investigate target identification, mechanism of action and resistance mechanism via deep proteomics analysis. Citation Format: Xiaoxi Xu, Marco Tognetti, Yuehan Feng, Limei Shang, Leilei Chen, Jessie Wang, Roland Bruderer, Ludovic Bourré, Henry Li. Identification of the phosphorylation network in PDX and corresponding organoid (PDXO) models upon targeted therapy treatment using deep phosphoproteomic analysis[MB1] [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 3110.