BACKGROUND: KRAS G12C-targeted therapies have transformed the treatment of KRAS G12C-mutant lung adenocarcinoma. However, acquired resistance to these therapies, whose underlying molecular mechanisms are not fully understood, presents a major obstacle to achieving long-term therapeutic success. The purpose of this study was to elucidate the mechanisms of acquired resistance to KRAS G12C inhibitors and identify potential regulators of resistance in lung adenocarcinoma. METHODS: Two lung adenocarcinoma cell lines (H23 and H2122) were exposed to escalating doses of two novel KRAS G12C inhibitors, fulzerasib and garsorasib, to generate resistant variants. Transcriptomic profiling was conducted to identify genes consistently upregulated in resistant cells. CRISPR/Cas9-mediated knockout (MXD4-KO) and siRNA-mediated knockdown of MXD4 were performed to assess its role in drug resistance. Mechanistic investigations employed inhibitors of ferroptosis, apoptosis, and necrosis, along with assays measuring lipid peroxidation and malondialdehyde levels. Further analysis included ferroptosis-related gene expression profiling, lipidomic profiling, ChIP-Seq, ChIP-qPCR, and dual-luciferase reporter assays. The findings were validated in patient-derived organoids (PDOs) and nude mouse models. RESULTS: Transcriptomic profiling identified 11 genes consistently upregulated in resistant cells, with MXD4 emerging as a key resistance regulator. CRISPR/Cas9-mediated knockout of MXD4 restored sensitivity to fulzerasib, garsorasib, sotorasib, and adagrasib, an effect fully reversed upon MXD4 re-overexpression. Similarly, siRNA-mediated knockdown of MXD4 in resistant cells restored drug sensitivity. Mechanistic studies revealed that MXD4 specifically suppresses ferroptosis, rather than apoptotic or necrotic pathways, by repressing ACSL4 expression and blocking its catalytic synthesis of phosphatidylethanolamine-polyunsaturated fatty acids (PE-PUFAs). ACSL4 knockout or overexpression abolished MXD4’s ability to promote ferroptosis suppression and resistance to KRAS G12C inhibitors. ChIP-Seq, ChIP-qPCR, and dual-luciferase reporter assays confirmed that MXD4 directly binds to and represses the ACSL4 promoter. These findings were validated in PDOs and nude mouse models, where MXD4 knockout restored therapeutic sensitivity, while ACSL4 knockout blocked MXD4’s resistance-promoting effects. CONCLUSIONS: This study uncovers a novel resistance mechanism in which MXD4 transcriptionally silences ACSL4 to suppress ferroptosis, enabling cancer cells to evade KRAS G12C inhibitors. Targeting the MXD4-ACSL4 axis represents a promising strategy to overcome therapeutic resistance in KRAS G12C-mutant lung cancer, potentially improving long-term treatment outcomes.

Background In ALINA (NCT03456076), a global, phase III, open-label study, alectinib, a highly selective, central nervous system (CNS)-active ALK inhibitor, demonstrated strong efficacy versus chemotherapy (disease-free survival [DFS] hazard ratio [HR]: 0.24) and was well tolerated in patients with resected ALK-positive NSCLC. We present an exploratory subgroup analysis of patients from ALINA who were enrolled in Asia. Methods Eligible patients aged ≥18 years with resected stage IB (≥4 cm)–IIIA (per UICC/AJCC 7th edition) ALK-positive NSCLC were randomized 1:1 to receive 600 mg oral alectinib (twice daily; 24 months) or intravenous platinum-based chemotherapy (four 21-day cycles). The primary endpoint was DFS. Secondary endpoints included overall survival (OS) and safety. CNS DFS was an exploratory endpoint. Safety was assessed in all randomized patients who received ≥1 dose of study drug. Results Overall, 140 patients were enrolled (alectinib arm: n=69; chemotherapy arm: n=71) in Asia (South Korea: n=49; mainland China: n=45; Japan: n=35; Taiwan: n=6; Thailand: n=5). At data cutoff (June 26, 2023), nine alectinib-treated patients (13%) and 22 chemotherapy-treated patients (31%) had experienced disease recurrence or death (DFS unstratified HR: 0.39; 95% CI: 0.18–0.85). The CNS-DFS unstratified HR was 0.24 (95% CI: 0.05–1.12). OS data were immature. No new safety concerns were observed, including in patients enrolled in Japan. Conclusions The treatment benefit of adjuvant alectinib observed in the Asia subgroup from ALINA was clinically meaningful and generally consistent with the global results, supporting that adjuvant alectinib is an efficacious treatment for patients with resected stage IB–IIIA ALK-positive NSCLC. Registered clinical trial ALINA: NCT03456076

Background Centrally located non-small cell lung cancer (NSCLC) traditionally requires sleeve resection or pneumonectomy. We investigated whether neoadjuvant chemoimmunotherapy (NeoCIT) could enable conversion to standard lobectomy and evaluated an artificial intelligence (AI)-assisted pure-vision and hyperspectral imaging (HSI) system for intraoperative margin assessment. Methods This multicenter cohort study enrolled patients from six tertiary referral centers in China between January 2019 and December 2025. The retrospective cohort (n=56, January 2019–December 2024) and prospective exploratory cohort (n=28, January–December 2025) included adults with histologically confirmed centrally located NSCLC initially indicated for sleeve resection who received neoadjuvant chemoimmunotherapy followed by surgical resection. Primary endpoints were event-free survival (EFS) and overall survival (OS), analyzed by Kaplan-Meier methods and multivariable Cox regression. The prospective cohort additionally underwent intraoperative bronchial margin assessment using an AI-assisted system combining hyperspectral imaging (HSI, 600–950 nm, 16 spectral bands) with a multi-layer perceptron (MLP)-based deep learning classifier for real-time pixel-wise tissue classification. Results In the retrospective cohort, 57.1% of patients achieved major pathologic response (MPR) or pathologic complete response (pCR), and 71.4% of them transitioned from sleeve lobectomy to lobectomy. The postoperative complication rate was significantly lower in the lobectomy group (10.0%) compared to the sleeve lobectomy group (38.5%, P=0.031). Two-year EFS was 69.9% for lobectomy versus 80.2% for sleeve resection (HR=0.76, P=0.665), with similar OS (84.0% vs 90.9%, HR=0.68, P=0.713). Multivariable analysis identified pCR/MPR, age, Eastern Cooperative Oncology Group (ECOG) status, and pathological nodal stage after neoadjuvant therapy (ypN) stage as independent prognostic factors. For the prospective cohort, the AI-assisted pure-vision and HSI system accurately assessed negative margins in real-time, showing high sensitivity (100%) and specificity (96.2%) compared to frozen-section pathology. Conclusion NeoCIT safely enables surgical conversion from sleeve resection to lobectomy in centrally located NSCLC without compromising oncologic outcomes, and AI-assisted hyperspectral imaging provides accurate real-time intraoperative bronchial margin assessment.

Lung adenocarcinoma, one of the most prevalent malignancies, underscores the urgency of identifying genes linked to its proliferation and prognosis for developing targeted therapies. In this study, we performed genome-wide CRISPR/Cas9 screening both in vitro and in vivo, and subsequently cross-referenced the findings with prognosis-related genes in lung adenocarcinoma. The screening results revealed that DEFB1 promotes lung adenocarcinoma proliferation, while our integrated analysis of single-cell sequencing, multiplex immunohistochemistry, TCGA, and GEO data concurrently demonstrated elevated DEFB1 expression in cancer cells, along with a negative correlation between DEFB1 expression and patient survival. Subsequently, functional studies employing DEFB1 knockout cells, re-expressed DEFB1 cells, and knockout cells supplemented with exogenous DEFB1 revealed that DEFB1 significantly enhances cell proliferation, migration, and invasion. Co-immunoprecipitation combined with mass spectrometry experiments was performed to uncover the mechanism of DEFB1, demonstrating that it interacts with Periplakin (PPL) to induce epithelial-to-mesenchymal transition (EMT) and proliferation, while simultaneously binding to Macrophage Migration Inhibitory Factor (MIF) to enhance M2 macrophage polarization. Furthermore, we developed multiple anti-DEFB1 monoclonal antibodies and found one of them, mAb-5, potently blocked DEFB1’s function and inhibited lung adenocarcinoma progression in cell lines, organoids, xenografts, and spontaneous lung cancer models, while maintaining a favorable safety profile. Overall, our study identifies DEFB1 as a novel driver of lung adenocarcinoma, and the anti-DEFB1 monoclonal antibody mAb-5 emerges as a promising therapeutic candidate with significant potential.

Gating strategy and knockdown efficiency.

Castleman disease (CD) is a rare lymphoproliferative disorder categorized into unicentric CD (UCD) and multicentric CD (MCD). Surgical intervention is crucial for both diagnosis and treatment. However, comprehensive comparisons and detailed analyses of surgical outcomes remain limited. We retrospectively reviewed thoracic CD patients treated at our hospital from 2010 to 2024. Clinical, pathological, laboratory, and imaging data were compared between UCD and MCD. Treatment outcomes and prognoses were assessed using multivariate Cox regression. We also compared outcomes between video-assisted thoracoscopic surgery (VATS) and open thoracotomy. Among 88 CD patients, 26.1

Enhanced glycolysis and lactate accumulation are shared features of human cancers. Lactylation is a lactate-derived posttranslational modification. So far, the impact of lactylation on resistance to osimertinib (a third-generation epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI)) in patients with lung adenocarcinoma (LUAD) remains indistinct. Here, we performed 4D label-free proteomics analysis of LUAD tissues from advanced-stage EGFR-mutant patients treated with surgery with or without neoadjuvant osimertinib to reveal a global lactylation profile and explore the role and molecular mechanism of protein lactylation in resistance to osimertinib. Through scanning the lactylated proteome, we discovered that α-Enolase 1 (ENO1), which acts as a key glycolytic enzyme, underwent lactylation at lysine 89 (K89) in LUAD tissues. The levels of ENO1 lactylation were notably attenuated in LUAD tissues after effective osimertinib treatment and were notably elevated in osimertinib-resistant LUAD cells. We found that monocarboxylate transporters (MCTs) facilitated lactate uptake into LUAD cells for ENO1 lactylation primarily through a p300/CREB-binding protein C (CBP)-dependent mechanism. ENO1 facilitated metabolic reprogramming and lactate production and interacted with several key metabolic enzymes, such as pyruvate kinase M1 (PKM1), pyruvate kinase M2 (PKM2), lactate dehydrogenase B (LDHB), and malate dehydrogenase 2 (MDH2), thus forming a tumor-derived lactate/ENO1 lactylation feedback loop, eventually contributing to osimertinib resistance in LUAD. In the in vivo orthotopic xenograft osimertinib-resistant models, targeted suppression of the tumor-derived lactate/ENO1 lactylation feedback loop effectively ameliorated resistance to osimertinib. Collectively, our findings provide the basis for targeting lactate/lactate-associated signaling to combat resistance to osimertinib.

ABSTRACTBackgroundPrimary pulmonary and bronchial adenoid cystic carcinoma (PACC) is a rare, low‐grade malignant tumor of the lung. However, the relationship between its clinical features, surgical prognosis, and genetic phenotype has not been fully described.MethodsPACC patient information was collected from the SEER, TCGA, and Zhongshan Hospital, Fudan University (FDZSH) databases. Overall survival (OS) was evaluated using the Kaplan–Meier method. Univariate and multivariate analyses through Cox proportional hazards regression identified risk factors that predicted OS. The limma and matfools packages from R were used to compare the differential genes and mutations between PACC and LUAD, respectively.ResultsTwo hundred and ninety‐two patients, 14 patients, and 12 patients with PACC were identified from the SEER, TCGA, and FDZSH databases, respectively. The 3‐, 5‐, and 10‐year OS of the PACC patients were 91.7%, 88.6%, and 85.0%, respectively, compared to 95.8%, 93.9%, and 93.3% for patients who underwent surgery. Race, pathological grade, M stage, regional node examination, and regional node positive were independent prognostic factors for the OS of patients who underwent surgery. The gene map of PACC and lung adenocarcinoma (LUAD) shows significant differences. Common mutations found in lung cancer were almost undetectable in PACC patients, whereas mutations in the NOTCH pathway were more common. TMB levels and PD‐1/PD‐L1 expressions were also lower in PACC patients.ConclusionOur study analyzed the main factors that influence the prognosis of PACC patients undergoing surgery and discovered the unique genetic phenotype of PACC.

RETSAT-RAR pathway promotes ferroptosis by activating SCD-mediated MUFA generation.

RETSAT links retinoid metabolism to ferroptosis.

Objective: This study aimed to compare the difference in perioperative outcomes and prognosis between neoadjuvant immunochemotherapy and neoadjuvant chemoradiotherapy for locally advanced esophageal squamous cell carcinoma. Methods: The patients with locally advanced esophageal squamous cell carcinoma receiving neoadjuvant immunochemotherapy or neoadjuvant chemoradiotherapy were identified from a prospectively maintained database at Zhongshan Hospital of Fudan University between January 2018 and March 2022. Propensity score matching was performed to balance the 2 groups. Results: A total of 124 patient pairs were enrolled in the fi nal analysis. The complete pathological response rate (20.2% vs 29.0%, P = .140) was similar in the 2 groups, whereas the lower major pathological response rate (44.4% vs 61.3%, P = .011) was observed in the neoadjuvant immunochemotherapy group. Neoadjuvant immunochemotherapy was associated with a lower rate of adverse events (42.7% vs 55.6%, P = .047) without additional postoperative complications (38.7% vs 35.5%, P = .693). The neoadjuvant immunochemotherapy group had lower distant metastasis (6.5% vs 16.1%, P = .027) and overall recurrence (11.3% vs 23.4%, P = .019) in the postoperative 1 year. Also, neoadjuvant immunochemotherapy was associated with better progression-free survival (hazard ratio, 0.50; 95% CI, 0.32-0.77; P = .002). Cox proportional hazard analysis showed that neoadjuvant immunochemotherapy (univariable: hazard ratio, 0.55; 95% CI, 0.37-0.82; P = .003; multivariable: hazard ratio, 0.44; 95% CI, 0.29-0.65; P < .001) was one of the independent prognostic factors for progression-free survival. The 2 groups had similar overall survival (hazard ratio, 0.62; 95% CI, 0.36-1.09; P = .094) at the latest follow-up. Conclusions: This retrospective study showed that neoadjuvant immunochemotherapy was safe and effective for patients with locally advanced esophageal squamous cell carcinoma. Further verification is needed in randomized controlled trials.

The legends for supplementary figure 1-7.

RETSAT-RAR-SCD signaling pathway regulates ferroptosis via MUFA generation, and targeting retinoid metabolism might be a promising strategy in future cancer treatment.

This Chinese expert consensus addresses comprehensive recommendations on biomarker testing, treatment, and follow-up in the perioperative management of patients with resectable ALK-fusion non-small cell lung cancer (NSCLC). The document highlights the pivotal role of cancer genomic testing in informing personalized therapeutic decision-making. The application of perioperative targeted therapies, including alectinib, has demonstrated significant potential in improving clinical outcomes for patients with ALK-fusion NSCLC. The consensus further underscores the necessity for expanded clinical research and trials to optimize and validate individualized treatment strategies, thereby advancing the standard of care in this patient population.

Objectives We compared the overall survival (OS) and cancer-specific survival (CSS) of patients who received radiotherapy and surgery, respectively, in a large population. Methods In this study, we counted the patients diagnosed with stage IA lung adenocarcinoma in the SEER database from 2015 to 2019. We compared the overall survival (OS) and cancer-specific survival (CSS) through Kaplan Meier analysis, balanced the differences of primary data through propensity score matching (PSM), screened independent prognostic factors through Cox regression analysis, and then compared the survival differences of different treatment methods through hierarchical analysis. Results Among 11,159 patients with stage IA lung adenocarcinoma, 4254 patients chose radiotherapy alone (38.1%), and 6688 patients were finally included through the propensity score matching. The median survival time for patients with radiotherapy alone was 53 months, while the patients with surgery alone did not reach the median survival time (p < 0.001). Multivariate analysis showed that age, sex, tumor size, and household income affected the prognosis of patients. The results of the stratified analysis showed that, except in the subgroup of age <= 50 years, almost all subgroup analyses showed that surgical treatment achieved better results. Conclusions Radiotherapy alone can be used as an option for patients with stage IA lung adenocarcinoma who cannot tolerate surgery, but the benefit to patients is limited, and surgical treatment may still be the best choice.

Background: 3-field lymph node dissection (3FL) frequently lead to much more perioperative complications than 2-field lymph node dissection (2FL). This study was designed as a non-inferiority trial to evaluate whether 3FL could be omitted without compromising overall survival (OS) and disease-free survival (DFS) in the patients with resectable thoracic esophageal squamous cell cancer (ESCC) and negative right recurrent laryngeal nerve lymph nodes (RRLN-LNs). Methods: cT1b-3N0-1M0 thoracic ESCC patients were managed in 3 arms during open or minimally invasive McKeown esophagectomy according to the results of frozen section examination for RRLN-LNs: if positive, direct 3FL (RRLN[ +]-3FL); if negative, 2FL (RRLN[-]-2FL) or 3FL (RRLN[-]-3FL) by randomization. Results: Based on frozen section, of the 829 finally recruited patients, 121 (13.6 %) had positive RRLN-LNs and direct 3FL (RRLN[ +]-3FL); 766 had negative RRLN-LNs and were randomized into the RRLN [-]-2FL (386 cases) or RRLN[-]-3FL (380 cases) group. The cervical LN metastasis rate in the RRLN[ +]-3FL group (28.9 %) was significantly higher than that in the RRLN[-]-3FL group (8.3 %) ( P < 0.001). The 5-year OS and DFS were 72.2 % and 65.1 % in the RRLN[-]-3FL group and 68.8 % and 62.8 % in the RRLN[-]-2FL group (OS, P = 0.163; DFS, P = 0.378), versus 50.3 % and 41.2 % in the RRLN[ +]-3FL group (both P < 0.001), respectively. Conclusions: Additional cervical lymphadenectomy can be avoided in the patients with middle or lower thoracic ESCC and negative RRLN-LNs by frozen section treated by upfront surgery.

RETSAT does not interfere with known ferroptosis regulators.

The resistance to KRAS-targeted therapies, particularly due to co-occurring gene mutations, remains a significant challenge. Through a metabolite library screening, we reveal that polyamines sensitize KRAS inhibitors only in KRASMU/KEAP1WT cells but not in KRASMU/KEAP1MU cells. Transcriptome sequencing and metabolome profiling pinpoint SAT1, the key enzyme in polyamine metabolism, as essential for this divergence. In KRASMU/KEAP1WT context, treatment of KRAS inhibitors activates JNK/c-Jun pathway and SAT1 expression, while the augmented SAT1 facilitates polyamine metabolism and KRAS inhibitors-induced ferroptosis. Conversely, in KRASMU/KEAP1MU cells, activated JNK promotes the degradation of NRF2, thereby inhibiting SAT1 expression. Our results further demonstrate that polyamine supplementation enhances KRAS-targeted therapy in KRASMU/KEAP1WT resistant cells, patient-derived organoids, xenografts, and spontaneously tumorigenic mice, while KRASMU/KEAP1MU models require lentivirus or adeno-associated virus-mediated SAT1 overexpression prior to polyamine treatment, to augment ferroptosis and drug sensitivity. Our findings highlight SAT1-mediated polyamine metabolism as a promising target in precision treatments for KRAS-mutant cancers.

Ferroptosis, an iron-dependent form of cell death, holds promise for cancer therapy. However, the intricate link between ferroptosis and oncogenic mutations remains unclear. Here we show that SMARCA4, a well-established tumour suppressor whose deficiency is associated with poor prognosis and resistance to treatments, sensitizes non-small cell lung cancer (NSCLC) cells to ferroptosis. Mechanistically, SMARCA4 promotes chromatin accessibility and expression of ALDH16A1. Surprisingly, ALDH16A1 lacks ALDH enzymatic activity, but binds to the anti-ferroptotic oxidoreductase thioredoxin (TXN), facilitating its translocation to the lysosome and subsequent degradation. Meanwhile, ALDH16A1 directly inhibits TXN's oxidoreductase function by occluding its active site. We also show that either restoring ALDH16A1 levels or inhibiting TXN significantly enhances the effectiveness of chemo/immunotherapy in a ferroptosis-dependent manner in SMARCA4-deficient NSCLC. Collectively, our findings elucidate an intricate SMARCA4-ALDH16A1-TXN stability/function dual regulatory axis that governs ferroptosis and informs a therapeutic strategy for overcoming resistance to chemotherapy or immunotherapy in SMARCA4-deficient NSCLC.