Supplemental Figure 4. A. Median progression-free survival and B. Overall survival for patients enrolled in the acquired resistance study

8517 Background: Patients (pts) with EGFR-mutant lung cancer (EGFR+LC) with active brain metastases (BrM) or leptomeningeal disease (LM) are often excluded from clinical trials. Despite central nervous system (CNS) disease control with osimertinib, > 50% of pts with EGFR-mutant lung cancer have involvement of the brain (BrM) or leptomeninges (LM). Amivantamab and lazertinib have demonstrated systemic activity in pts with EGFR-mutant lung cancer whose disease progressed after osimertinib and/or platinum-based chemotherapy. This trial evaluated amivantamab +lazertinib in the setting of progressive CNS metastases (NCT04965090). Methods: We evaluated amivantamab and lazertinib in 2 cohorts: pts with 1) progressive or new BrM or 2) LM. All pts with EGFR exon 19 del/L858R/atypical mutations had prior osimertinib. All pts with EGFRexon 20 insertions (ex20ins) had prior chemotherapy. Each cohort was to enroll 20 pts powered to differentiate overall response rate (ORR) of 0.05 vs 0.25. Positive CSF assessment (cytology or circulating tumor cells (CTC)) +/- BrM allocated a pt to the LM cohort. Pts received standard dosing of amivantamab and lazertinib 240 mg daily. Co-primary endpoints were systemic ORR by RECIST v1.1 and CNS ORR by RANO-BM or LM. Paired pre-treatment tumor, blood, and CSF samples had targeted DNA sequencing and cell-free RNA (cfRNA) sequencing. Results: Trial enrolled 20 pts in BrM cohort and 22 pts in LM cohort. Median age 55 (range 31-80), 69% women,. 40% had L858R (n = 17), 40% del19 (n = 17), 12% ex20 ins (n = 5), and 8% atypical EGFR mutations (n = 3). Median lines of prior therapy: 2 (1-7). Except patients with ex20ins, all patients had prior osimertinib, and 55% had chemo. Efficacy Data: . 14 LM pts (64%) had decrease in CSF CTCs and 7 (32%) had improvement in neurologic symptoms. Most frequent treatment-related adverse events (TRAEs) (≥30% in overall population) were rash (71%), infusion-related reaction (59%), paronychia (43%), fatigue (40%), edema (40%), mucositis (33%), and nausea (33%). Most frequent (≥5%) grade ≥3 TRAEs were infusion related reactions (7%), thromboembolic event (5%), elevated AST/ALT (5%), and rash (5%). Three pts (7%) discontinued treatment due to TRAEs. Genomic data comparing concurrent systemic tumor, plasma and CSF samples, and ctDNA and cfRNA dynamics will be presented. Conclusions: The combination of amivantamab+lazertinib is a promising treatment for pts with EGFR-mutant lung cancer and active CNS disease, with clinically meaningful time on treatment and radiographic response. This is the first clinical trial successfully completed in pts with EGFR-mutant lung cancer and progressive CNS metastases. Clinical trial information: NCT04965090 .[Table: see text]

PDF file - 76K, Examples of negative results with the NanoString assay for kinase fusions.

PDF file - 76K, Comprehensive list of mutations tested by mass spectrometry (Sequenom)

PDF file - 54K, Morphologic assessment of tumors harboring EGFR exon 20 insertions and comparison to a control group with classical EGFR sensitizing mutations

Neoadjuvant immune checkpoint inhibitor therapies are well tolerated and may be of benefit in early-stage non-small cell lung cancer (NSCLC). Here we report clinical and biomarker data from the Phase II LCMC3 (NCT02927301) study evaluating pre-operative treatment with atezolizumab (anti-PD-L1) in patients with untreated stage IB to IIIB resectable NSCLC.

Even though osimertinib (osi) is now the initial treatment for patients with EGFR-mutant lung cancers, our knowledge about mechanisms of resistance (MOR) is largely derived from patients who received osi after acquiring EGFR T790M on treatment with another EGFR inhibitor. Other studies of osi resistance have mainly reported genotyping of plasma which suboptimally detects lineage plasticity, copy number changes, and chromosomal rearrangements. To identify MOR to osi and characterize clinical, molecular and histologic factors associated with duration of response, we identified patients with EGFR-mutant lung cancers who had targeted next-generation sequencing (MSK-IMPACT) performed on tumor tissue obtained before treatment and after developing resistance to osi received as either first-line or later line EGFR-TKI. From January 2016 to March 2019, we collected paired pre-treatment and resistance specimens from 53 patients (1st line osi: 21. Osi after prior TKI: 32). MOR are summarized in the table. Histologic transformation was identified in 18% of 1st line cases and 17% of all cases. When osi was given as initial treatment, with median follow up of 18 months, early emerging MOR rarely included on-target resistance mechanisms (acquired EGFR G724S in 1/21). Other acquired alterations representing potential resistance mechanisms not listed in the table included CCNE1 and MYC amplifications, and mutations in MTOR A1098S and MET H1094Y.Tabled 1First line (n = 21)Osi after prior TKI (n = 32)All (n = 53)Squamous transformation336Neuroendocrine transformation123On target mutation (EGFR C797X or other)1910Loss of EGFR T790M only-88Fusions (ALK, RET, BRAF)033Amplifications (HER2, MET, EGFR)234Off target mutations (KRAS, BRAF, HER2)123 Open table in a new tab In this analysis of MOR identified on NGS from tumor tissue, we found a spectrum of resistance mechanisms to osi. By evaluating tissue rather than plasma we provide data on histologic transformation (including squamous cell transformation). Subsequent studies are needed to assess patients with a longer time on initial osi as early progressors may have different MOR, with off-target MOR emerging earlier and on-target resistance mutations later.

The immune mechanisms dictating response and resistance to PD-(L)1 blockade are not well understood in early stage non-small cell lung cancer (NSCLC). Understanding these mechanisms will be key to improve outcomes and identify the next generation of predictive biomarkers of response to these therapies. Here, we present updated immunophenotyping at time of interim analysis of LCMC3, a multicenter trial of neoadjuvant atezolizumab in resectable NSCLC (NCT02927301). Patients received 2 cycles of atezolizumab before resection. Tumor, LN biopsies and PB were obtained pre-atezolizumab and at surgery. Paired PB, screening and surgical LN were analyzed using IMMUNOME flow cytometry. Plasma-based cytokine arrays were performed on a subset of patients. Immunophenotypic analyses were correlated with treatment effect, major pathologic response (MPR, primary endpoint) and preoperative treatment-related adverse events (preop-TRAE). We report on 55 patients with paired PB samples (analyzed within 72h after collection) and completed surgery. We observed preop-TRAE in 32/55 patients (18 grade 1, 13 grade 2, 1 grade 3). CD1c+ and CD141+ myeloid cells (MC) were lower at baseline in patients developing preop-TRAEs, while monocytic M-MDSCs were higher in those patients. Senescent T cells decreased in patients with preop-TRAE and increased in patients with non-preop-TRAE. After treatment, the absolute cell counts of late activated CD4+and CD8+T cells decreased in patients achieving MPR. LN IMMUNOME data, cytokine data and 12-month follow-up (DFS, OS) will be reported. Preliminary immunophenotyping data from the interim analysis showed significantly lower baseline immunosuppressive cell subsets in patients with preop-TRAE and decreased late activated CD4+and CD8+T cells from PB in patients with MPR.These results, together with additional LN IMMUNOME and cytokine analyses, may improve our understanding of immunophenotypic features associated with outcome, and changes induced by neoadjuvant atezolizumab in early stage NSCLC patients.

Targeted therapy for Class I BRAF mutant lung cancers (V600) is well described and there is growing literature on their response to immune checkpoint inhibitors (ICI). In contrast, the molecular characteristics, immunophenotype, and response rates of class II and III BRAF mutations are not well defined.

To date, no ROS1 inhibitor is approved for the treatment of ROS1-rearranged lung cancers after progression on crizotinib. Progression on crizotinib can be mediated by the acquisition of ROS1 kinase domain mutations (e.g. ROS1G2032R or ROS1D2033N). Cabozantinib is a highly potent ROS1 tyrosine kinase inhibitor that has superior activity over lorlatinib against these mutations. We evaluated the activity of cabozantinib in patients with ROS1-rearranged lung cancers on a phase 2 trial.

Recent efforts to characterize the germline genetic landscape of MPM have uncovered a surprising prevalence of pathogenic variants in DNA-damage sensing and repair genes. Increasingly, next-generation sequencing has helped bring new insight into critical mutations or pathways involved in the development of MPM. Additionally, observations from these studies could direct new screening, prevention, and therapeutic approaches for patients and families. With IRB approval, we performed deidentified analysis on 87 additional cancer-predisposing genes on our NGS platform among patients with MPM previously consented to a BAP1 germline testing protocol. Additionally, germline variants in an additional 380 genes associated with somatic alterations in cancer, but not associated with hereditary cancer predisposition, were screened for loss of function variant or pathogenic entries in ClinVar. All variants were reviewed according to the American College of Medical Genetics and Genomics and Association for Molecular Pathology consensus guidelines. Founder mutations were excluded. Clinicopathologic information was also collected. Comparisons were done using Fisher’s exact test. P values <0.05 were considered significant. Of 88 patients with MPM analyzed, 11% (10/88) had pathogenic variants. Clinical characteristics such as age, sex, histology, and self-reported asbestos exposure, were similar between patients with and without pathogenic variants (Table 1). Pathogenic variants previously unreported in mesothelioma were identified: MSH3 1/88 (1%; 95% CI: 0-7%), BARD1 1/88 (1%; 95% CI: 0-7%), and RECQL4 2/88 (2%; 95% CI: 0-8%). We also identified pathogenic variants previously associated with mesothelioma: BAP1 in 3/88 (3%; 95% CI: 1-10%), BRCA2 1/88 (1%; 95% CI: 0-7%), and MRE11A 1/88 (1%; 95% CI: 0-7%). One patient had a potentially pathogenic alteration in SHQ1, which has not been associated with a heightened susceptibility to cancer. Patients with germline pathogenic variants were more likely to have more than 2 first-degree family members with cancer compared to those without germline mutations (40% vs 13%; p = 0.049). While the overall incidence of germline mutations identified is similar to prior reports, we identified germline pathogenic alterations in three DNA damage repair and replication genes not previously reported in mesothelioma. Furthermore, we describe a novel germline alteration in SHQ1, which has not been reported with hereditary cancer predisposition. Whether these variants increase the risk of mesothelioma is still under investigation, but given the high rate of germline pathogenic variant in individuals with pleural mesothelioma, germline testing for hereditary cancer susceptibility should be considered in all patients with MPM.

MET exon 14 (METex14) alterations are targetable drivers found in 3-4% of lung cancers. The frequency of intracranial disease and patterns of central nervous system (CNS) progression on MET tyrosine kinase inhibitors (TKI) are not well characterized. Patients with advanced METex14-altered lung cancers identified by next-generation sequencing (MSK-IMPACT) between January 2014 and March 2018 were eligible for analysis. A retrospective review of clinical features, patterns of metastases, and CNS progression on MET-TKI was performed. The frequency of intracranial disease was compared to cohorts single-center of EGFR-mutant (n=200), ERBB2-mutant (n=98) and KRAS-mutant (n=200) lung cancers. 82 patients with metastatic METex14-altered lung cancers were identified. The median age was 73; 56% (n=46) were female and 54% (n=44) were former smokers. The frequency of brain metastases at baseline was 11% (n=9/82). The lifetime frequency of intracranial metastases from diagnosis of metastatic disease was 34% (n=28/82). By comparison, the frequency of brain metastases was 47% (94/200, p=0.05) with EGFR-, 47% (46/98), p=0.09) with ERBB2-, and 32% (64/200, p=0.78) with KRAS-driven tumors. 6% (n=5/82) of patients developed leptomeningeal disease. The overall survival (OS) of patients who developed intracranial disease on therapy compared to those who did not develop intracranial disease was not significantly different (HR 0.66, 95% CI 0.30-1.43, p=0.29). 51 patients received crizotinib, 26 of whom developed progressive disease. The frequency of intracranial (alone), intracranial and extracranial, and extracranial (alone) progression was 8% (2/26), 19% (5/26), and 73% (19/26), respectively. A third of patients with METex14-altered lung cancers develop intracranial disease. This proportion is lower than that seen in EGFR- and ERBB2-mutant lung cancers and comparable to KRAS-mutant lung cancers. The frequency of CNS failure on crizotinib was lower than expected compared to historical rates in ALK-rearranged lung cancers.

20% of patients with metastatic lung adenocarcinoma have activating EGFR-mutations. EGFR-mutant lung cancers can undergo histologic transformation to small cell lung cancer (SCLC) as a response to the selective pressure of EGFR-TKIs in <5% of patients after earlier-generation EGFR-TKIs and have been reported after osimertinib. SCLC nearly universally harbor TP53/RB1-alterations which are rarely seen in EGFR-mutant lung adenocarcinomas. We sought to identify this subset of patients, describe their clinical course and likelihood of SCLC transformation. Retrospective review of targeted next generation sequencing (NGS, MSK-IMACT) at Memorial Sloan Kettering (MSK) was performed to identify patients with concurrent EGFR-activating mutations and TP53/RB1-mutations within the same tumor sample from NGS between April 2014 to February 2018 with a data cutoff of March 2018. For comparison, consecutive patients with lung cancers harboring EGFR-mutations who were EGFR-TKI naïve and TP53/RB1-wildtype were also collected during that time-period. Of the 21% of lung cancer patients with activating EGFR-mutations (759/3662), 5% (40/759) had concurrent TP53/RB1-mutations. 43% (17/40) were female, 58% former-smokers (23/40, median pack-years: 8), and median age of 68 (range 25-86 years). 88% (35/40) were adenocarcinoma at diagnosis, of which 11% (4/35) transformed to SCLC during treatment; 10% (4/40) were de-novo SCLC at diagnosis, and 1 was large cell neuroendocrine. The transformation rate was significantly higher compared to previous work from MSK evaluating EGFR-mutant patients showing 4% (4/155) transformation (p=0.04). Concurrent PIK3CA mutations were more frequently seen in the EGFR/TP53/RB1 mutant group compared to the TP53/RB1-wildtype group (17% (n=6/35) vs 7% (n=4/60), p=0.11). 20 patients were EGFR TKI-naïve at the time of NGS; the median time on EGFR-TKI (ToT) was 7.6 months versus 14.2 months in the TP53/RB1-wildtype group (HR 4.48, p=0.0003). The overall survival (OS) of this cohort versus TP53/RB1-wildtype was not different (4.3 vs 4.1 years, HR 1.35, p=0.51). In the 4 patients with SCLC transformation, the median time to transformation was 2.4 years after a median of 1.5 EGFR-TKI therapies (range 1-5 lines). Median OS from time of transformation was 7 months. 63% (25/40) of the EGFR/TP53/RB1-mutant cohort had brain metastases during their disease course as compared to 50% (n=30) in the TP53/RB1-wildtype group (p=0.30). SCLC transformation is enriched in EGFR/TP53/RB1-mutant lung cancers, occurring in 11% of patients. Once SCLC transformation occurs, overall survival is short. Patients with EGFR/TP53/RB1 have a shorter time on EGFR-TKI. Further investigation into optimal treatment for this subset of EGFR/TP53/RB1 mutant lung cancers is critical.

Therapeutic options for squamous cell lung cancer (SQCLC) patients remain limited. Platinum-based chemotherapies, which have been the standard first-line treatments for nearly 20 years, are associated with ORR=30-40%, median PFS=4-5.7mo, and median OS=9-11.5mo. We previously reported the results of a phase 1/2 trial of albumin-bound paclitaxel (ABP) in 40 patients with untreated stage IV NSCLC, noting an ORR of 30%, median PFS of 5mo, and median OS of 11mo (Rizvi JCO 2008). These data suggest that platinum adds little when coupled to ABP.

ABSTRACT Aim: LCNEC is a rare thoracic malignancy, for which pathologic classification and optimal therapies are debated. We report the largest series of stage IV LCNECs, evaluating clinicopathologic features, treatment and survival. Methods: Pts with stage IV LCNEC evaluated at MSKCC from 2006-2013 were identified. Clinicopathologic and treatment data were collected. Radiologic RECIST evaluation was performed for pts with existing diagnostic imaging. Pts with available tissue underwent pathology re-review to confirm diagnosis, and potentially identify features that could impact outcomes. Results: 50 pts were identified (median age: 66 years; 62% male; 88% former/current smokers). Common sites of metastasis: lymph nodes (n = 29); brain (n = 22); liver (n = 13). 34% of pts had diagnostic molecular testing with PCR-based fragment length analysis, mass spectrometry based assay for point mutation genotyping, and ALK FISH testing: 24% had KRAS mutations (mtns) (n = 4/17; G12D, n = 2; G12C, n = 1; Q61H, n = 1). No EGFR mtns or ALK rearrangements were noted. 33 pts had archived tumor at MSKCC for central pathology re-review. The diagnosis of LCNEC was confirmed in all but 2 cases, which were reclassified as SCLC and combined SCLC/LCNEC (both brain metastases), respectively. Treatment data was available on 39 pts: 77% (n = 30) received first-line platinum(plt)/etoposide. 23% (n = 9) received other regimens: plt/taxane (n = 4), plt/pemetrexed (n = 1), plt/pemetrexed/bevacizumab(bev) (n = 1), temozolomide (n = 1)/bev (n = 1), clinical trial (n = 1). Objective response rate was 32% with plt/etoposide by RECIST (95% CI: 16-52%). Median OS was 12.2mos (range: 9-19.3mos) for all pts. Karnofsky performance status 250 were poor prognostic factors for OS on multivariate analysis (p Conclusions: Pts with stage IV LCNEC have low response to plt/etoposide treatment and poor OS. KRAS mutations are commonly observed. Prospective studies are needed to investigate optimum therapeutic strategies. Disclosure: All authors have declared no conflicts of interest.