Survival outcome within oligoAR and sysAR subgroups

Survival outcome of the overall study population

PURPOSE:Dabrafenib plus trametinib is a standard first-line treatment for BRAF V600E-mutated non-small cell lung cancer (NSCLC). The LiBRA study aimed to explore the role of liquid biopsy in detecting and monitoring BRAF V600E mutation, assessing its potential to predict treatment response and emerging resistance. MATERIALS AND METHODS:This prospective multicenter study enrolled patients with BRAF V600E-mutated NSCLC treated with first-line dabrafenib plus trametinib. Plasma samples were collected at baseline (t0), after 4 weeks (t1), and longitudinally until disease progression (PD). BRAF V600E was monitored by digital droplet PCR (ddPCR). Next-generation sequencing (NGS) was performed at t0 and PD to identify resistance mechanisms. RESULTS:Forty patients were enrolled. Dabrafenib plus trametinib achieved an overall response rate of 42.5%, with a median progression-free survival (PFS) and overall survival (OS) of 8.3 and 21.1 months, respectively. At t0, BRAF V600E was detectable by ddPCR in 24 (62%) of 39 patients. Among 21 shedders evaluated at t1, 17 (81%) cleared the mutation. Higher baseline BRAF V600E allele frequency was associated with shorter PFS (hazard ratio [HR], 1.09, P = .013) and OS (HR, 1.10, P = .010), whereas clearance at t1 correlated with longer PFS (8.3 v 1.4 months, P < .001) and OS (10.5 v 2.2 months, P < .001). Biological PD anticipated radiologic/clinical PD by a median of 4.9 weeks (IQR, 1.4-9.8). Baseline EGFR and MET CNVs were associated with shorter PFS and OS. Resistance mechanisms at PD included NRAS, KRAS, TP53 mutations and MET, EGFR, ERBB2 CNVs. CONCLUSION:The LiBRA study supports liquid biopsy as a prognostic and monitoring tool in BRAF V600E-mutated NSCLC undergoing targeted therapy.

1663 Background: Older patients with advanced cancer are a highly heterogeneous population, in whom geriatric vulnerability may significantly influence survival, treatment tolerance, and patient-reported outcomes. The G8 screening tool is a validated instrument designed to identify geriatric vulnerability and select patients for comprehensive geriatric assessment; however, its prognostic and longitudinal impact on quality of life in patients receiving novel anticancer therapies remains poorly explored. Methods: The ONC-OLD study prospectively enrolled patients aged ≥70 years with advanced cancer treated with novel therapies across six referral centers. The primary objective was to assess the prognostic impact of baseline G8-defined geriatric vulnerability on overall survival (OS). Geriatric vulnerability was assessed at baseline using the G8 screening tool (≤14 vs >14). Health-related quality of life (HRQoL) was assessed using the EORTC QLQ-C30 and QLQ-ELD14 at baseline, after 3 months, and at disease progression. Baseline associations were analyzed using multivariable regression models, while longitudinal HRQoL changes were assessed using ANCOVA adjusted for baseline scores and relevant clinical covariates. Results: A total of 143 patients were included (median age 78 years, IQR 75-82); 78% had ECOG performance status (PS) 0-1, and 73% had G8 ≤14. Treatments consisted mainly of immunotherapy, either as monotherapy (31%) or in combination (36%), and targeted therapy (30%). At baseline, patients with G8 ≤14 were older (≥80 years: 46% vs 20%, p=0.019), more frequently female (42% vs 16%, p=0.016), and had worse ECOG PS (PS ≥2: 25% vs 0%, p=0.005) compared with those with G8 >14, with a different distribution of primary tumor types (lung cancer: 67% vs 29%, p=0.001). Median OS was 16.1 months (95% CI, 13.4-not reached) and was significantly shorter in patients with G8 ≤14 compared with those with G8 >14 (14.2 vs not reached; p=0.019). G8 ≤14 was independently associated with an increased risk of death (HR 2.71, 95% CI 1.01-7.24; p=0.047), after adjustment for ECOG PS, number of metastatic sites, treatment line and type. G8 ≤14 was associated with a trend toward a higher risk of grade ≥3 adverse events (OR 2.00, 95% CI 0.69-7.25; p=0.23), without specific treatment-related safety signals. At baseline, patients with impaired G8 reported worse global health, physical and role functioning, fatigue, pain, and mobility (all p≤0.01). In longitudinal analyses adjusted for baseline HRQoL and clinical covariates (ECOG PS, age, treatment), G8 remained significantly associated with higher fatigue (+12.6 points; p=0.039). Conclusions: Baseline G8 impairment is associated with poorer survival, worse baseline HRQoL, and a higher risk of severe toxicity, supporting the clinical value of G8 screening in older patients treated with novel therapies.

Representativeness of Study Participants

BACKGROUND:The immunonutritional background has been deeply implicated in cancer behavior and clinical outcomes. In this study, we explored the prognostic impact of the Controlling Nutritional Status (CONUT) score through its correlation with blood immunophenotypes and cytokines to provide an easily available non-invasive tool to predict the survival benefit from first-line immune checkpoint inhibitors±chemotherapy (ICI±CHT) in patients affected by advanced non-small cell lung cancer (aNSCLC). MATERIAL AND METHODS:From a prospective cohort of patients with aNSCLC treated with first-line ICI±CHT, clinicopathological data and baseline blood samples for the assessment of CONUT score (albumin, lymphocytes, total cholesterol), relevant immunophenotypes (flow cytometry) and cytokines (multiplex array) were collected. Correlations of CONUT score with survival outcomes (progression-free/overall survival [PFS/OS]) and circulating immune-inflammatory benchmarks were analyzed. RESULTS:Among 178 patients enrolled in the AIRC (Italian Association for Cancer Research) project, 153 received ICI±CHT as first-line. Nutritional status tested by CONUT score was available in 137 cases and was <3, meaning good nutritional status, in 77 (56.2%), whereas scored ≥3 in 60 (43.8%), meaning an impaired nutritional status. At a median follow-up of 27.4 months (95% CI 22.9 to 32.0), patients with a CONUT score <3, compared to those with CONUT score ≥3, experienced significantly longer PFS (median PFS 8.03 vs 3.88 months, HR 0.58, 95% CI 0.40 to 0.84, p=0.004) and OS (median OS 22.24 vs 8.75 months, HR 0.61, 95% CI 0.40 to 0.94, p=0.03). The multivariable analysis, adjusting for age, histology, metastatic sites, sex, programmed death-ligand 1 (PD-L1), Eastern Cooperative Oncology Group Performance Status and treatment type, confirmed the prognostic impact of CONUT score in terms of PFS (HR 0.61, 95% CI 0.41 to 0.93, p=0.02) and OS (HR 0.60, 95% CI 0.38 to 0.96 p=0.03). Patients with CONUT score ≥3 displayed significantly higher blood levels of interleukin (IL)-1β, IL-12, IL-10, interferon-γ, IL-6, and soluble PD-L1 compared with those with CONUT score <3. A higher fraction of CD14+ cells (p=0.01) and CD8+Ki67+ (p<0.001) lymphocytes also characterized the blood of patients with CONUT score ≥3 compared with those with CONUT score <3. CONCLUSION:A baseline good nutritional status (CONUT score <3) is associated with a distinct circulating immune-inflammatory profile and correlates with improved clinical outcomes in patients with aNSCLC treated with first-line ICI±CHT.

Delta radiomic profiling of oligoAR and sysAR patients

Immune checkpoint inhibitors (ICIs) have improved outcomes for patients with solid tumors, but reliable predictors of overall survival (OS) are limited. This retrospective study of 146 advanced solid tumor patients treated with ICIs aims to provide a nomogram to predict 1-year (1y) OS integrating body composition (BC) parameters with standard clinicopathological (CP) features. A two-stage approach was implemented: first random survival forest models were trained and tested to evaluate the prognostic value of (a) CP features alone, (b) BC metrics alone or as newly introduced BC scores, and (c) their combination. The best predictive performance (average cumulative AUC of 0.73 in test set) was achieved by combining 12 CP features with the BC score comprising intramuscolar adipose tissue content, visceral fat area index, and the visceral-to-subcutaneous fat area index ratio. Finally, a nomogram was developed with this feature set, offering a tool for personalized risk stratification and treatment planning (mean absolute error in calibration curve of 0.03 and overall AUC of 0.76). Integrating BC parameters with CP features substantially enhances 1y OS prediction in patients receiving ICIs.

Technical parameters of CT volumes selected for segmentation

Response rates by treatment arm and Trop-2 median H-score subgroup in the Trop-2 biomarker evaluable population.

Kaplan-Meier plots for OS by treatment arm for the (A) ITT, (B) Trop-2 biomarker evaluable population, and (C) ctDNA biomarker evaluable population.

List of antibodies employed for FACS analysis

BACKGROUND:Patient-reported symptom monitoring may improve the outcomes of cancer treatment. Knowledge of psychometric properties may drive the selection of optimal tools. Here we report the analysis of PRO-CTCAE in Italian lung cancer patients. METHODS:A PRO-CTCAE list (74 items, 44 symptoms) was administered to on-treatment patients at registration (visit 1) and after 2-6 weeks (visit 2). Convergent validity with EORTC LC-13 and Hospital Anxiety and Depression Scale (HADS) was assessed by Pearson correlation. Known-group validity and responsiveness were tested with ECOG performance status (PS 0 vs 1) and Patients' Global Impression of Change (PGIC) scale as anchors, respectively. RESULTS:From September 2019 to November 2022, 186 patients filled PRO-CTCAE at visit 1 and 164 at visit 2. Median age (IQR) was 66.4 (60.9 - 73.1) years; 58.6% were male; 68.0% had PS 0. Convergent validity showed high correlation (r ≥ 0.50) of PRO-CTCAE hair loss (r = 0.78), dyspnoea (0.63), limb numbness (0.63), cough (0.58) and pain (0.51) with selected LC-13 anchors. PRO-CTCAE anxiety, depression and sadness highly correlated with HADS. For known-group validity, small to medium correlations were found for oral, cutaneous and respiratory toxicity, fatigue, appetite loss, insomnia and depression, that were worse for PS 1; limb swelling and pain were worse in PS 0. Responsiveness analysis at visit 2 found some PRO-CTCAE score changes consistently and directly correlated with impression of change measured with PGIC. CONCLUSIONS:These results support the use of selected PRO-CTCAE items for lung cancer patients as a reliable tool for detection of treatment related toxicities.

ELIOS (NCT03239340) prospectively compared tumor biopsies obtained pre-treatment and post-progression to characterize acquired resistance mechanisms to first-line osimertinib in epidermal growth factor receptor (EGFR)-mutant advanced non-small cell lung cancer (NSCLC). Of 154 patients enrolled, 52 patients had next-generation sequencing (NGS) results from paired tissue biopsies. The most common acquired alterations at progression were MET amplification (17%), deletion of CDKN2A/CDKN2B (15%) and MTAP (13%), and EGFR C797S (13%). Proteogenomic analysis (n = 32 at baseline and n = 18 post-progression) showed TROP2 was highly expressed at baseline and post-progression, irrespective of genetic alterations observed. In a separate analysis of patients with matched tissue and plasma samples post-progression (n = 51), 82% had potential resistance alterations by NGS, demonstrating the complementary roles of tissue and plasma NGS. These results highlight the challenges of obtaining tissue biopsies in patients with NSCLC progressing on targeted therapy, the potential for heterogeneous resistance, and the need for broad-acting treatment strategies. SIGNIFICANCE:ELIOS confirmed acquired resistance mechanisms to first-line osimertinib in a prospective, molecular profiling study of paired pre- and post-treatment tissue samples and provided the first proteogenomic characterization before/after osimertinib, identifying novel proteomic markers. ELIOS showed the potential for heterogeneous resistance, highlighting that strategies targeting multiple resistance pathways may be required.

BACKGROUND:Immune checkpoint inhibitor (ICI) monotherapy is the standard first-line treatment for advanced non-small cell lung cancer (NSCLC) with PD-L1 ≥ 50%; however, up to 30% of patients experience early progression or death, including cases of hyperprogressive disease (HPD). High baseline levels (≥ 30.5%) of circulating CD10- low-density neutrophils (LDNs) have been associated with increased HPD occurrence. Emerging evidence suggests that combining ICI with platinum-based chemotherapy (PCT) may mitigate the risk of HPD. Currently, no prospective studies have addressed HPD prevention in this context. PATIENTS AND METHODS:HYPERBOLIC (NCT07274384) is a phase 2, randomized, open-label, multicenter, international trial evaluating whether adding 3 cycles of PCT to first-line cemiplimab reduces HPD rate in stage IV NSCLC with PD-L1 ≥ 50% and CD10- LDNs (identified by flow cytometry as CD15⁺CD11b⁺ within the PBMC fraction, with immature cells defined by loss of CD10) ≥ 30.5%. Seventy-four patients will be randomized (1:1 ratio) to receive cemiplimab alone or cemiplimab plus 3 PCT cycles, followed by cemiplimab maintenance. Randomization will be stratified by Lung Immune Prognostic Index. The first computed tomography scan at week 7 after treatment start will assess HPD occurrence, defined as RECIST v 1.1. disease progression with a delta tumor growth rate (ΔTGR) ≥ 50% and/or TGR ratio ≥ 2. The primary endpoint will be the combined rate of HPD and early death (death within 12 weeks with no radiological evaluation). Secondary endpoints will be HPD rate according to alternative definitions, overall survival, progression free survival, objective response rate, and safety. An extensive translational research platform will include spatial transcriptomics of tumor tissue, single-cell RNA sequencing of PBMCs, circulating-free DNA and plasma factors profiling, and saliva/stool microbiome genomics and metabolomics, to longitudinally explore tumor-host dynamic interactions during treatment. CONCLUSION:to our knowledge, HYPERBOLIC is the first prospective, biomarker-driven trial investigating early treatment escalation based on HPD risk in PD-L1-high NSCLC.

Statistically different baseline radiomic features in oligoAR vs sysAR patients

Baseline immune-inflammatory profile of oligoAR and sysAR patients with NSCLC

8647 Background: BRAF V600E mutations occur in approximately 2–3% of non–small cell lung cancer (NSCLC). BRAF/MEK inhibition (BRAFi+MEKi) yields high response rates and durable clinical benefit but acquired resistance is inevitable. BRAFi+MEKi therapy may select for resistant tumor clones, induce secondary genomic alterations, and drive changes in the tumor immunophenotype. However, the landscape of resistance mechanisms to BRAFi+MEKi in NSCLC remains largely unknown. Methods: We conducted a global, multicenter analysis of patients with advanced BRAF V600E–mutant NSCLC treated with BRAFi±MEKi across multiple academic centers and available public datasets. Eligible patients had matched pre- and post-treatment next-generation sequencing (NGS). Analyses were restricted to oncogenic or likely oncogenic alterations per OncoKB and/or ClinVar. Results: Among 33 patients with matched pre- and post– BRAFi±MEKi samples, median age was 66 years; 39.4% were women, 67.7% had a history of tobacco use, and 97.0% had adenocarcinoma at diagnosis. Objective response to BRAFi±MEKi in this cohort was 81.8%, while median progression-free survival was 8 months; only 3 patients (9.1%) had primary resistance. Acquired resistance mechanisms were diverse, encompassing reactivation of the RAS/RAF/ERK signaling pathway (via BRAF -dependent and BRAF -independent mechanisms), activation of alternative bypass pathways (e.g. PI3K/AKT and HIPPO), and alterations associated with cell-cycle dysregulation. Concurrent resistance mechanisms were identified in 12.1% of cases, and one patient developed histologic transformation to small-cell lung cancer (SCLC). No identifiable resistance mechanism was detected in 11 patients (33.3%). The most common acquired genomic alterations were RAS mutations, observed in 21.2% of cases ( NRAS Q61K, n = 1; NRAS Q61R, n = 1; KRAS G12D, n = 1; KRAS G12V, n = 1; KRAS Q61R, n = 1; NRAS Q61R + KRAS 61H, n = 1; KRAS G12V + KRAS Q61H, n = 1), followed by MET amplifications (12.1%, n = 4). Additional acquired events included BRAF kinase-domain duplication, MAP2K1 and NF2 mutations, and FGFR4 amplification. Putative resistance alterations involving DNA damage repair genes (e.g., CHEK2, BRIP1) were also identified. Clinically, one patient with acquired MET amplification showed loss of the MET -amplified clone on liquid biopsy after adding crizotinib to BRAFi+MEKi, without grade≥3 adverse events, suggesting a potentially targetable resistance mechanism with therapeutic implications. Conclusions: Our findings define the genomic landscape of acquired resistance to BRAFi+MEKi in BRAF V600E–mutant NSCLC and highlight the emergence of diverse resistance mechanisms, including SCLC transformation, MET amplification, and RAS mutations, several of which are potentially actionable and may inform rational post-BRAFi/MEKi therapeutic strategies.

Gating strategy adopted for flow cytometric (FACS) analyses