Background:Although first-line immunotherapy has expanded treatment options for advanced non-small cell lung cancer (NSCLC) without actionable genomic alterations (AGA), real-world patterns and outcomes of later-line therapies remain poorly defined. This study aimed to characterize these later-line treatment patterns and evaluate their clinical outcomes. Methods:The RECAP study retrospectively analyzed 383 Chinese patients with advanced NSCLC who had unknown or no AGAs and received second-line (2L; n=302) or third-line (3L; n=81) therapy. Treatment regimens were classified as anti-angiogenic (A), chemotherapy (C), chemotherapy-based combinations (C+), immunotherapy (I), immunotherapy-based combinations (I+), and other regimens (O). Results:Treatment patterns, real-world progression-free survival (rwPFS), time to treatment discontinuation (TTD), time to next treatment or death (TTNT), and adverse events (AEs) were collected. In the 2L-enrolled group, the most common regimen was I + C (30.5%), while A + C (21.0%) predominated in the 3L-enrolled group. In the 2L-enrolled group, I + C regimen remained common across treatment lines, while the use of the A regimen increased in the 3L. Median rwPFS was 7.0 months [95% confidence interval (CI): 5.9-9.6] for 2L therapy in the 2L-enrolled group and 7.2 months (95% CI: 5.0-12.8) for 3L therapy in the 3L-enrolled group. I + A achieved the longest rwPFS for 2L therapy in the 2L-enrolled group (13.7 months), and I + A + C for 3L in the 3L-enrolled group (13.6 months). AEs occurred in 13.1% of patients. Conclusions:The RECAP study underscores the prominent role of I+ regimens in later-line settings, with I + C commonly used across treatment lines. These I+ regimens demonstrated favorable clinical outcomes in both 2L and 3L enrolled patients. However, these findings should be interpreted with caution because of the retrospective design, treatment heterogeneity, and exploratory nature of the analyses.
Background:Prognostic serum biomarkers of immune checkpoint inhibitor (ICI) efficacy in non-small cell lung cancer (NSCLC) are sparse. We evaluated baseline cytokines as markers of outcomes in ICI-treated metastatic NSCLC. Methods:Baseline serum cytokines were quantified in 96 patients with metastatic NSCLC receiving ICIs. Separate multivariable models were fit for progression-free survival (PFS) and overall survival (OS), adjusting for clinical covariates. Hazard ratios (HRs) were expressed per doubling in cytokine concentration. Significant cytokines were then incorporated into multivariable Cox models, and model discrimination was assessed using time-dependent area under the curve (AUC). Latent class analysis (LCA) was performed to identify cytokine-defined patient phenotypes associated with survival. Results:Each doubling of interleukin-6 (IL-6) increased the hazard of death by 34% [HR =1.34; 95% confidence interval (CI): 1.13-1.60; P<0.001] and interleukin-8 (IL-8) by 36% (HR =1.36; 95% CI: 1.16-1.59; P<0.001). Conversely, each doubling of interferon-omega (IFN-ω) (HR =0.87; 95% CI: 0.80-0.95; P=0.001) and perforin (HR =0.50; 95% CI: 0.33-0.76; P<0.001) decreased mortality risk. Multivariable cytokine models incorporating IL-6, IL-8, IFN-ω, and perforin achieved time-dependent AUCs >0.70 for PFS and OS. LCA identified two cytokine classes: one enriched for IL-6/IL-8 (poor outcomes) and another enriched for IFN-ω/perforin (favorable outcomes). Conclusions:Higher baseline serum IL-6 and IL-8 concentrations were associated with inferior survival, whereas higher baseline serum IFN-ω and perforin were associated with improved survival in ICI-treated metastatic NSCLC, defining distinct host immune-inflammatory phenotypes with prognostic relevance.
Background and Objective:Lung cancer ranks among the most prevalent malignancies globally. Despite progress in early detection and standard therapies lowering overall mortality, there remains an urgent demand for optimized combinatorial regimens, reliable biomarkers and individualized strategies to advance precision lung cancer care. Epigenetic-targeted agents, represented by DNA methylation and histone lysine deacetylase (HDAC) inhibitors, have exhibited encouraging anti-tumor effects, and the Food and Drug Administration (FDA)-approved EZH2 inhibitor tazemetostat has further validated the translational value of epigenetic therapy across multiple tumors. This narrative review systematically summarizes epigenetic alterations and corresponding targeted inhibitors in lung cancer, and clarifies the clinical prospects of epigenetic tools for diagnostic biomarker development and stratified precision treatment. Methods:We searched PubMed and Web of Science Core Collection from database inception to January 31, 2026 with keywords covering lung cancer, DNA methylation, histone modification and epigenetic targeted therapy. Only full-text English original articles and reviews were retained. Key Content and Findings:This review systematically characterizes aberrant epigenetic signatures in lung cancer, encompassing DNA methylation, histone methylation, and the recently discovered histone lactylation, while detailing epigenetic biomarkers applicable to diagnosis and targeted therapy. We further summarize subtype-specific research advances of KMT/KDM, HDAC, EZH2 and LSD1 inhibitors in distinct lung cancer subtypes, with core functions including suppressing tumor proliferation, modulating neuroendocrine phenotypic transition, reversing therapeutic resistance, and amplifying anti-tumor immune responses. Conclusions:Dysregulated epigenetic modifications serve as core drivers of lung cancer progression, and various epigenetic small-molecule inhibitors possess broad application potential for lung cancer precision treatment. Combined regimens integrating epigenetic agents with immunotherapy or chemotherapy can strengthen anti-tumor responses, yet subtype heterogeneity and unsatisfactory clinical efficacy of some targeted drugs remain major obstacles. The accumulated preclinical and clinical epigenetic evidence summarized herein provides solid theoretical support for developing novel diagnostic biomarkers and individualized stratified therapeutic strategies against lung cancer.
Background:Histopathological evaluation of lung biopsy specimens is inherently destructive and reduces the three-dimensional tissue architecture to limited two-dimensional sections. For small bronchoscopic specimens, this may compromise the optimal tissue utilization for diagnosis and molecular testing. We investigated whether synchrotron-based phase-contrast X-ray computed tomography (CT) could be used to non-destructively visualize the three-dimensional architecture of clinically obtained transbronchial cryobiopsy specimens. Methods:In this exploratory imaging study, we prospectively enrolled patients with peripheral pulmonary lesions who underwent bronchoscopy. An additional single cryobiopsy specimen was obtained and imaged using synchrotron-based phase-contrast CT. The structural features were evaluated by three blinded observers using predefined ordinal scores. Interobserver agreement was assessed using the weighted kappa and intraclass correlation coefficients. Representative cases underwent serial histological sectioning, and exploratory slow-freezing micro-CT imaging was performed on a subset. Results:Fifteen patients were included. Phase-contrast CT revealed major structural features including alveolar-like airspaces, tissue density, glandular lumina, solid nest-like structures, thickened bronchial wall structures, and calcified foci. The imaging findings generally corresponded to the histological findings. Interobserver agreement was moderate to substantial for airspace preservation and tissue density, whereas agreement was poor for glandular and solid nest-like structures. Exploratory micro-CT showed partial visualization of finer structures but was limited by image blurring and distortion. Conclusions:Synchrotron-based phase-contrast CT enabled non-destructive three-dimensional structural visualization of clinically obtained transbronchial cryobiopsy specimens. Although the current resolution remains insufficient for detailed histological classification, this study represents a proof-of-concept for the feasibility of this imaging technique rather than a clinical workflow utility.
Background:Despite advances in stage I-III non-small cell lung cancer (NSCLC) treatment, curative-intent therapy is withheld in patients deemed ineligible or preferring no treatment. Limited real-world data exist on overall and cancer-related survival outcomes in patients receiving primary best supportive care (BSC). The main aim of this study was to compare median overall survival (OS) by reason for BSC (patient preference versus other factors). Methods:We retrospectively analyzed overall and lung cancer-specific survival (LCSS) in patients with stage I-III NSCLC diagnosed between 2015 and 2019 in the Netherlands. Patients received primary BSC or curative treatment (surgery, radiotherapy or chemoradiation). The BSC cohort was categorized by main decisive factor: (I) patient preference; (II) insufficient performance status; or (III) relevant comorbidities. Survival data were compared using log-rank tests and Cox regression models. Results:Out of 1,895 patients, 234 (12%) received primary BSC, including 82 based on patient preference. Median OS was 5.9 months in the total BCS cohort and 9.6 months in the patient-preference cohort, compared to 54.1 months in the curative treatment cohort [hazard ratio (HR) 0.17; 95% confidence interval (CI): 0.13-0.22; P<0.001]. Median LCSS was 8.9 and 16.4 months in the total BSC and patient-preference cohort, respectively, versus not reached in the curative treatment cohort (HR 0.15; 95% CI: 0.11-0.21; P<0.001). These survival differences remained significant after adjusting for relevant confounders. Conclusions:In routine clinical practice, primary BSC was provided in a substantial proportion of patients with stage I-III NSCLC, due to medical reasons or patient preference. In either case, omission of curative treatment resulted in significantly reduced survival outcomes. Our data offer targeted evidence to guide treatment decisions in the outpatient oncology clinic.
Background:Resistance to epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) remains common in patients with EGFR-mutant or ALK rearrangement non-small cell lung cancer (NSCLC). Mesenchymal-epithelial transition (MET) overexpression plays a key role in acquired resistance. However, real-world evidence on combined tyrosine kinase inhibition targeting both EGFR/ALK drivers and MET is limited. This study aimed to evaluate the efficacy and safety of combined EGFR/ALK and MET inhibition in this population. Methods:We performed a single-center, retrospective cohort study of NSCLC patients with EGFR mutations or ALK rearrangements who developed resistance to prior EGFR/ALK-targeted therapies and exhibited MET overexpression. Eligible patients received combined treatment with EGFR/ALK TKIs and MET inhibitors. Treatment responses were assessed using Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1), and progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Results:Data of a total of 23 patients were analyzed. The objective response rate (ORR) was 69.6%, with partial responses in 16 patients and stable disease in 6. Median PFS was 6.9 months. High-level MET overexpression, defined as immunohistochemistry (IHC) 3+, was associated with a higher response rate compared to MET IHC 2+. The treatment was generally well-tolerated, with most adverse events being low-grade and manageable. Conclusions:Dual inhibition of EGFR/ALK and MET offers promising antitumor activity with an acceptable safety profile in EGFR/ALK-mutant NSCLC patients with MET overexpression, providing a viable strategy for overcoming acquired resistance.
Background and Objective:Stage III non-small cell lung cancer (NSCLC) is a heterogeneous disease with outcomes limited by distant failure, treatment-related toxicities, and loss of immune fitness during chemoradiation. Randomized trials support perioperative immunotherapy (IO) for resectable disease and consolidation durvalumab after concurrent chemoradiotherapy (cCRT) for unresectable disease. Immune-preserving radiotherapy (RT)-encompassing immune organ-at-risk (iOAR) and effective dose to immune cells (EDIC)-aware planning, judicious hypofractionation, and stereotactic body radiation therapy (SBRT) or spatially fractionated radiation therapy (SFRT)-is an emerging lever to optimize immune competence during treatment. This study aims to synthesize contemporary evidence for stage IIIA/IIIB management through a dual-track framework (resectable versus unresectable disease), outline practical algorithms integrating surgery, RT, and systemic therapy, and highlight translational strategies including SFRT and tumor-infiltrating lymphocyte (TIL)-based approaches, while clearly distinguishing established standards from investigational concepts. Methods:We conducted a narrative review of pivotal trials and practice-shaping studies, emphasizing perioperative IO (neoadjuvant chemo-IO ± adjuvant IO), the PACIFIC paradigm, RT dose/fractionation strategies, and approaches to mitigate RT-related lymphopenia. We propose an evidence-anchored clinical pathway and a checklist for immune-preserving RT. Key Content and Findings:Neoadjuvant nivolumab-chemotherapy improves pathological complete response (pCR), event-free survival (EFS), and overall survival (OS) in resectable disease (CheckMate 816). Perioperative pembrolizumab (KEYNOTE-671), durvalumab (AEGEAN), and nivolumab (CheckMate 77T) significantly prolong EFS. In unresectable stage III, durvalumab after cCRT confers durable OS benefit (5-year OS 42.9%), whereas uniform dose escalation to 74 Gy did not improve survival. RT-related lymphopenia is frequent and prognostic; reducing low-dose bath, minimizing exposure to iOARs, and optimizing target selection may preserve immune competence. SBRT/SFRT integrations and TIL-based cellular approaches warrant prospective testing but remain investigational. Conclusions:A dual-track algorithm-perioperative chemo-IO for operable IIIA and cCRT followed by durvalumab for unresectable IIIA/IIIB-remains the evidence-based standard. Refinements that prioritize immune preservation (iOAR-aware planning, limited-field and hypofractionated strategies) represent promising areas of investigation that should not compromise tumor control. In patients with oncogene-driven disease, targeted therapy should be considered. When surgical resection is performed, tissue acquisition for molecular profiling and, in the context of clinical trials, TIL expansion may support personalized treatment strategies. These investigational approaches require prospective validation.
Background and Objective:Kirsten rat sarcoma viral oncogene homolog (KRAS)-G12D is a common oncogenic mutation in non-small cell lung cancer (NSCLC) and has posed significant challenges in the development of treatment approaches that specifically target this alteration. KRAS-G12D differs from KRAS-G12C in its biochemical and signal transduction features, which limits the use of drugs targeting the KRAS-G12C mutation, creating substantial demands in clinical contexts. This review sought to summarize the major developments in treatment for KRAS-G12D-mutant NSCLC, with a focus on the recent key advances and emerging clinical data on targeted therapies. Methods:A comprehensive literature search was conducted using electronic databases, including PubMed, Web of Science, and Google Scholar, supplemented by manual searching of reference lists and related articles. The review focused on preclinical and clinical research on KRAS-G12D-targeted therapies and indirect regulatory inhibitors. Key Content and Findings:Rapid progress has been made in development of therapies targeting KRAS-G12D. A variety of direct-targeting strategies, including allele-selective non-covalent inhibitors, RAS in the active guanosine triphosphate (GTP) state [RAS (ON)] selective inhibitors, and targeted protein degradation (TPD) agents, have shown the feasibility of inhibiting the KRAS-G12D signaling pathway in preclinical and early clinical studies. The indirect inhibition of upstream regulators, such as son of sevenless homolog 1 (SOS1) and Src-homology-2-containing protein tyrosine phosphatase 2 (SHP2), and the blocking of downstream pathways have also provided important treatments that combine multiple approaches. In addition, co-mutation patterns, the tumor immune microenvironment, and adaptive resistance mechanisms significantly influence therapeutic responses and clinical outcomes. Conclusions:Driven by diverse drug discovery platforms and mechanism-based combination strategies, KRAS-G12D targeting is rapidly transitioning from conceptual validation to clinical application. These advances provide new opportunities for the precision treatment of NSCLC.
Background:Although most patients with stage I non-small cell lung cancer (NSCLC) are detected at an early and potentially curable stage, postoperative recurrence and mortality still occur after curative resection. Whether presenting symptoms at diagnosis provide additional prognostic information for risk stratification in surgically treated stage I NSCLC remains unclear. This study evaluated the association between symptoms at diagnosis and long-term outcomes in patients with pathologically confirmed stage I NSCLC. Methods:This retrospective cohort study used single-institution data from West China Hospital, Sichuan University, within the Western China Lung Cancer Database, a prospectively maintained institutional registry. Patients with pathologically confirmed stage IA-IB NSCLC who underwent curative-intent surgical resection between 2011 and 2021 were included. Patients receiving non-surgical primary treatment, undergoing non-curative resection, or lacking detailed survival or treatment information were excluded. Presenting symptoms were extracted from electronic medical records at diagnosis. Baseline demographic, clinical, surgical, and pathological covariates were collected. Follow-up was conducted through outpatient visits, hospital record review, and telephone interviews. Cox regression models were used to evaluate associations with overall survival (OS) and disease-free survival (DFS). Results:A total of 9,205 patients were included, of whom 2,657 (28.9%) were symptomatic at diagnosis. The most common symptoms were cough, chest pain, and blood-tinged sputum. Symptomatic patients were more likely to be older, male, smokers, and to have chronic obstructive pulmonary disease (COPD) or squamous cell carcinoma histology. Symptom presence was independently associated with poorer OS [adjusted hazard ratio (HR) =1.22, 95% confidence interval (CI): 1.01-1.47; P=0.03] and DFS (adjusted HR =1.27, 95% CI: 1.09-1.47; P=0.002). Among individual symptoms, blood-tinged sputum remained independently associated with worse OS (adjusted HR =1.71, 95% CI: 1.31-2.24; P<0.001) and DFS (adjusted HR =1.71, 95% CI: 1.36-2.14; P<0.001) after adjustment for demographic, clinical, surgical, and pathological covariates. Conclusions:Presenting symptoms at diagnosis, particularly blood-tinged sputum, was associated with poorer long-term outcomes in patients with surgically treated stage I NSCLC. Symptom status may provide a simple clinical cue for postoperative risk stratification and may help identify patients who require closer surveillance after curative resection.
Background:Smoking cessation lowers lung cancer (LC) risk, but the magnitude of risk reduction varies across individuals. FOXO3, a key regulator of cellular stress-response and longevity pathways, may influence susceptibility to LC after smoking cessation. The aim of the present study was to investigate whether FOXO3 genotype modifies the association between smoking cessation and incident LC. Methods:We examined 4,339 ever-smoking American men of Japanese ancestry who were free of LC at baseline in the Kuakini Japan-Hawaii Cancer Study (1971-1975; mean age, 60 years). Participants were genotyped for FOXO3 rs2802292 and classified as FOXO3-G (TG/GG; longevity-associated G-allele carriers) or FOXO3-TT (TT, common allele homozygotes). Smoking status (former or current), cumulative exposure (pack-years), and duration of smoking cessation (years; current smokers assigned 0) were assessed. Incident LC cases through 1999 were identified. Cox proportional hazards models adjusted for potential confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), and test interactions. Results:During 28 years of follow-up, 180 LC cases occurred, including 117 non-small cell lung cancer (NSCLC) cases. Significant interactions were observed between smoking status and FOXO3 genotype for LC (P=0.02) and NSCLC (P=0.003). Among former smokers, FOXO3-G carriers had a lower risk than FOXO3-TT carriers (LC: HR, 0.42; 95% CI, 0.23-0.79; NSCLC: HR, 0.23; 95% CI, 0.09-0.60). In contrast, no genotype-related differences were observed among current smokers. Among FOXO3-G carriers, each additional year of smoking cessation was associated with a reduced risk of LC (HR, 0.87; 95% CI, 0.81-0.94) and NSCLC (HR, 0.72; 95% CI, 0.58-0.89), whereas only weaker associations were observed among FOXO3-TT carriers (LC: HR, 0.97; 95% CI, 0.94-1.00; NSCLC: HR, 0.98; 95% CI, 0.94-1.01). Conclusions:FOXO3 genotype may modify LC risk associated with smoking cessation. Compared with carriers of the longevity-associated FOXO3 G allele, individuals with the FOXO3-TT genotype had a substantially elevated risk of LC after smoking cessation; this association was not observed among current smokers. These findings support the potential for genotype-informed precision prevention, pending replication in larger and more diverse cohorts.
Background:Sublobar resection (SLR) has become the standard treatment for patients with peripheral early-stage non-small cell lung cancer (NSCLC). Identifying the risk factors contributing to prolonged length of stay (LOS) after SLR is critical to improving surgical service efficiency. This study aimed to identify the predictors of prolonged LOS in patients with NSCLC who have undergone SLR. Methods:This retrospective study included consecutive patients with NSCLC who underwent SLR between 2011 and 2021 at West China Hospital. The primary outcome was the association between clinicopathological factors and prolonged LOS (defined as an LOS exceeding the median LOS). Multivariate logistic regression analysis was performed to identify the predictors of prolonged LOS. Results:Overall, 4,173 patients were included in the study (wedge resection: n=1,287; segmentectomy: n=2,886). The median postoperative LOS was 3 and 4 days in the wedge resection and segmentectomy groups, respectively. Advanced age, male sex, symptoms at presentation, larger size of the main lesion, and longer operative time were significantly associated with prolonged LOS in both the wedge and segmentectomy groups. A higher percent predicted forced expiratory volume in the first second was a protective factor for prolonged LOS after SLR, whereas a higher percent predicted diffusion capacity for carbon monoxide was a protective factor specifically for segmentectomy. Conclusions:Male sex, advanced age, symptoms at presentation, larger main lesion size, longer operative time, and impaired lung function were risk factors for a prolonged LOS after SLR. Candidates for SLR with these risk factors require heightened attention during clinical planning and postoperative management.
Background:Chemo-immunotherapy is the standard first-line treatment for extensive-disease small-cell lung cancer (ED-SCLC), but biomarkers for benefit remain limited. Serum neuron-specific enolase (NSE) is a classical small-cell lung cancer (SCLC) biomarker, but its relationship with the tumor immune microenvironment remains unclear. This study aimed to evaluate the association of pretreatment serum NSE with clinical outcomes and intratumoral CD8-positive lymphocyte infiltration in patients with ED-SCLC. Methods:We retrospectively analyzed pathologically confirmed ED-SCLC patients who received first-line chemo-immunotherapy or chemotherapy. Pretreatment serum NSE was measured by electrochemiluminescence immunoassay (ECLIA). Progression-free survival (PFS) and overall survival (OS) were evaluated by NSE status. Tumor biopsy specimens were assessed for human leukocyte antigen (HLA) class I expression and CD8-positive lymphocyte infiltration. Cox models, treatment-by-NSE interaction analyses, log-transformed NSE analyses, and logistic regression for CD8 infiltration were performed. Results:A serum NSE threshold of 64.1 ng/mL stratified patients into low- and high-NSE groups. In the chemo-immunotherapy cohort, high NSE remained independently associated with shorter PFS after adjustment for performance status (PS), stage group, liver metastasis, and brain metastasis [hazard ratio (HR), 3.68; 95% confidence interval (CI): 1.39-9.76; P=0.009]. Treatment-by-NSE interaction was significant for PFS (HR, 4.52; 95% CI: 1.27-16.10; P=0.02). CD8-positive lymphocyte infiltration was more frequent in the low-NSE group. Low NSE was independently associated with CD8-positive lymphocyte infiltration after adjustment for HLA class I expression, PS, liver metastasis, and brain metastasis [odds ratio (OR), 11.68; 95% CI: 3.01-61.32; P=0.001]. Conclusions:Pretreatment serum NSE was associated with survival outcomes and CD8-positive lymphocyte infiltration in ED-SCLC. Serum NSE may serve as a clinically accessible prognostic marker and exploratory stratification biomarker for chemo-immunotherapy benefit, particularly for PFS.
Background:The current International Association for the Study of Lung Cancer (IASLC) grading system for invasive pulmonary adenocarcinoma excludes invasive mucinous adenocarcinoma (IMA) and mixed IMA, limiting its prognostic scope. We aimed to refine the IASLC grading system by incorporating IMA and mixed IMA, and to validate it in large-scale cohorts. Methods:This single-institutional study included 692 patients with stage I-III lung invasive adenocarcinoma from Shanghai Chest Hospital (training cohort) and 7,862 from the Surveillance, Epidemiology, and End Results (SEER) database (validation cohort). We introduced IMA and reclassified the IASLC grading system. Prognostic performance was assessed using Harrell C-index, time-dependent receiver operating characteristic (ROC) curves and areas under the curve (AUCs). Overall survival (OS) curves were estimated via the Kaplan-Meier method, with log-rank test for difference comparison. Results:Mucinous predominant tumors with <20% of high-grade patterns (solid, micro papillary, complex glandular patterns) were classified as the Grade 2 (moderately differentiated). The proposed expanded grading system demonstrated improved prognostic accuracy, with C-index and AUC values of 0.713 and 0.739 in the training cohort, and 0.707 and 0.742 in the validation cohort, respectively. The 5-year OS rates for Grade 1, Grade 2, and Grade 3 were 87.5%, 73.1%, and 55.5% in the training cohort (P<0.001), and 80.2%, 67.3%, and 60.0% in the validation cohort (P<0.001). The proposed expanded grading system demonstrated superior prognostic performance compared to the current IASLC grading system in both cohorts. Conclusions:The proposed expanded IASLC grading system was practical and prognostic for lung invasive adenocarcinoma, and the introduction of IMA could improve its applicability.
Background and Objective:Lung cancer remains the leading cause of cancer-related death worldwide. Many patients are still facing limited treatment benefit or therapeutic resistance. Single-cell RNA sequencing (scRNA-seq) enables high-resolution characterization of cellular states, whereas spatial transcriptomics (ST) preserves tissue architecture and maps gene expression within the tumor microenvironment (TME). This review summarizes recent advances in scRNA-seq and ST in lung cancer and discusses how these technologies have improved our understanding of tumor biology and therapeutic response. Methods:A literature search was conducted in PubMed/MEDLINE for English-language studies published between January 2020 and 2025 using terms related to lung cancer, single-cell sequencing, single-nucleus sequencing, and spatial transcriptomics. Key Content and Findings:Recent studies have used scRNA-seq and ST to characterize immune and stromal compartments, tumor cell heterogeneity, early cancer evolution, metastasis, and treatment-associated remodeling. These findings suggest that lung cancer progression is shaped not only by genetic alterations but also by transcriptional plasticity, spatially organized TME niches, and dynamic interactions between tumor, immune, and stromal cells. Conclusions:scRNA-seq and ST have shifted lung cancer research from bulk tumor profiling toward cellular and spatial ecosystem analysis. However, many proposed biomarkers and therapeutic targets remain exploratory. Further spatial validation, functional experiments, and clinically annotated cohorts are needed before these findings can be translated into routine precision medicine.
Background:Postoperative recurrence remains a major challenge after curative-intent resection for non-small cell lung cancer (NSCLC), and conventional clinicopathologic factors do not fully capture recurrence risk heterogeneity. Although computed tomography (CT)-derived body composition biomarkers have been associated with outcomes in NSCLC, the prognostic relevance of abdominal solid-organ volumetrics remains insufficiently characterized. We investigated whether preoperative CT-derived abdominal organ volumes and body surface area (BSA)-normalized organ indices were associated with recurrence-related outcomes in resected NSCLC. Methods:This multicenter retrospective cohort study included 1,762 patients with clinically and pathologically confirmed NSCLC who underwent curative-intent resection at five centers and had preoperative CT within 1 month before surgery. A healthy control cohort of 3,263 individuals was included for baseline organ-volumetric comparison. Clinical and laboratory variables were extracted from preoperative records, with laboratory tests generally obtained within 7 days before surgery. A deep learning-based automated segmentation pipeline quantified the spleen, liver, pancreas, bilateral kidneys, and bilateral adrenal glands, and organ indices were normalized to BSA. Propensity score matching (PSM) was restricted to patient-control organ-volumetric comparisons. Recurrence was ascertained from follow-up clinical and imaging records. Recurrence-free survival (RFS) and disease-free survival (DFS) were evaluated as recurrence-related outcomes. Multivariable Cox models were performed in the full NSCLC cohort and adjusted for age, sex, T stage, pathological types, diabetes, hypertension, smoking, drinking, body mass index (BMI), albumin, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR). Results:The NSCLC cohort had a median age of 60 years, and 934 patients (53.0%) were women. During median follow-up periods of 39.7 months for RFS and 39.4 months for DFS, 198 RFS events and 219 DFS events occurred. Compared with healthy controls after PSM, patients with NSCLC showed larger spleen, liver, kidney, and adrenal volumes and smaller pancreatic volume. In multivariable Cox analyses, lower pancreatic volume and pancreatic index were independently associated with shorter RFS [hazard ratio (HR) =0.735, P<0.001; HR =0.729, P<0.001, respectively] and DFS (HR =0.791, P=0.002; HR =0.787, P=0.001, respectively). Lower left adrenal gland index (LAGI) was also associated with shorter RFS (HR =0.845, P=0.030) and DFS (HR =0.833, P=0.01). Lower liver volume (LVV) index was associated with RFS only (HR =0.834, P=0.02), whereas lower left adrenal gland volume (LAGV) was associated with DFS only (HR =0.843, P=0.03). Conclusions:Preoperative CT-derived abdominal organ volumetrics, particularly pancreatic and left adrenal gland metrics, were independently associated with recurrence-related outcomes after curative-intent resection of NSCLC. These imaging biomarkers may provide complementary information for postoperative recurrence risk stratification. Further prospective validation is warranted.
Background:The regulatory approval of the delta-like ligand 3 (DLL3)-directed bispecific T-cell engager tarlatamab has positioned DLL3 as a clinically actionable target in small-cell lung cancer (SCLC), yet whether DLL3 is independently prognostic alongside other therapy-relevant proteins in real-world SCLC cohorts remains unknown. We addressed this using standardized mass spectrometry-based absolute quantitation. Methods:We applied selected reaction monitoring-mass spectrometry (SRM-MS) to archival formalin-fixed paraffin-embedded tumor tissue from 100 patients with SCLC treated with first-line platinum/etoposide (2005-2015), quantifying nine therapy-relevant proteins (DLL3, ASCL1, EZH2, SLFN11, TYMP, MGMT, CD56, TUBB3, TOPO1) in absolute molar units. Associations with tumor stage, platinum-sensitivity status, and overall survival (OS) were analyzed. Results:SRM-MS yielded interpretable measurements in all 100 tumors. DLL3 was tightly stage-linked, detected in 76% of extensive-stage versus 29% of limited-stage tumors (area under the receiver operating characteristic curve 0.78; P<0.001). A four-class DLL3/ASCL1 model stratified OS (P=0.004); however, stage-stratified analyses showed that this signal was confined to limited-stage disease and largely driven by a small DLL3-/ASCL1- subgroup (n=9, median OS 25.8 months). In multivariable Cox regression, detectable TYMP emerged as an independent predictor of shorter OS. Conclusions:Multiplexed SRM-MS is clinically applicable to routinely archived FFPE SCLC tissue and provides a quantitative framework that may help address the unmet clinical need for biomarker-guided patient selection in SCLC, particularly in the era of DLL3-directed therapy.
Background:Small cell lung cancer (SCLC) is an aggressive neuroendocrine tumor. While chemotherapy has been the cornerstone of first-line treatment, most SCLC patients develop chemoresistance shortly after an initial response, and the molecular basis of this resistance remains poorly understood. This study aims to identify novel drivers of SCLC chemoresistance. Methods:FOXA1 copy number alterations and expression patterns were analyzed using public databases and validated by immunoblotting and immunohistochemistry. The functional role of FOXA1 in chemoresistance was determined through in vitro and in vivo gain- and loss-of-function assays. RNA sequencing and chromatin immunoprecipitation sequencing were performed to investigate underlying mechanisms. The functional significance of FOXA1-WNT5A-Wnt axis was tested using genetic perturbations and pharmacological inhibition. Results:FOXA1 was a frequently amplified and upregulated gene in SCLC. FOXA1 overexpression promoted resistance to chemotherapy. Mechanistically, WNT5A was identified as a direct downstream target of FOXA1, mediating chemoresistance through activation of the Wnt/β-catenin pathway. FOXA1 also induced epithelial-mesenchymal transition (EMT) in SCLC cells. Consistently, human SCLC tumors with elevated FOXA1 expression exhibited enriched EMT and Wnt/β-catenin pathway signatures. Importantly, pharmacological inhibition of the Wnt pathway selectively suppressed the growth of FOXA1-overexpressing SCLC cells. Conclusions:This study identifies FOXA1 as a key driver of chemoresistance in SCLC and highlights Wnt pathway inhibition as a promising therapeutic strategy to overcome FOXA1-driven chemoresistance.
