Background In this population-based cohort, we examined the prevalence of targetable genomic alterations and characterized KRAS subtypes in relation to co-mutations, PD-L1 expression, treatment, and survival. Materials and Methods A total of 880 patients diagnosed with lung adenocarcinoma in Central Denmark in 2020–2021 underwent reflex next-generation sequencing using a 22-gene panel. Results KRAS mutations were present in 383/880 tumors (43.5%), of which KRAS G12C accounted for 174 cases (19.8% of the total cohort). Overall, targetable alterations were identified in 327/880 tumors (37.2%). KRAS G12C mutations were more frequent in females and smokers. KRAS mutations were largely mutually exclusive with other targetable driver alterations. TP53 mutations were more common in KRAS wild-type tumors, whereas non-G12C KRAS mutations were associated with SMAD4 mutations. PD-L1 ≥50% occurred most frequently in tumors with KRAS G12C.KRAS mutation status was not associated with overall survival in unadjusted analyses. After adjustment for clinical covariates, non-G12C KRAS mutations showed a modest association with increased mortality. Among 628 patients with available treatment data, survival differed across treatment modalities. Among patients receiving systemic first-line treatment (n=183), survival was significantly better with immune checkpoint inhibitors or targeted therapy than with chemotherapy (p<0.001). KRAS mutation status was not associated with treatment-specific survival in any treatment group. Conclusion Lung adenocarcinomas are characterized by a high prevalence of targetable alterations, with KRAS G12C representing the most frequent alteration. KRAS mutation status showed limited prognostic relevance. These findings support routine molecular testing and integration of genomic and clinical data to guide personalized treatment.

Abstract The detection of circulating tumor DNA (ctDNA) through the identification of somatic mutations has shown promising results for monitoring treatment response in cancer patients. However, mutation-based approaches are limited by factors such as clonal hematopoiesis, low sensitivity, and the inability to detect epigenetic tumor signals. Complementary approaches based on epigenetic profiling of cell-free DNA (cfDNA) in liquid biopsies have been developed to infer the gene expression profile in the cells of cfDNA origin. We investigated the application of cell-free chromatin immunoprecipitation (cfChIP) targeting H3K4me3 and H3K36me3 histone modifications of circulating nucleosomes in non-small cell lung cancer (NSCLC) patients treated with immunotherapy or targeted therapies. ctDNA dynamics were quantified using targeted sequencing of cfDNA to identify molecular responders to treatment based on ctDNA clearance. We performed cfChIP on healthy individuals and cancer patients followed by ddPCR or whole-genome sequencing at baseline, a few weeks after treatment initiation and at progression. High FGD2 expression and low CDH3 expression at baseline were associated with a durable response to immunotherapy. Genes, in which the cfChIP enrichment correlated with ctDNA burden included genes, such as PLCE1 and VASH2, involved in developmental processes. Longitudinal monitoring of MET gene activity with H3K36me3 cfChIP ddPCR distinguished patients with crizotinib response from non-responders. cfChIP at progression indicated novel resistance mechanisms to targeted therapy through upregulation of genes such as FOXG1 and MT3, involved in neural development. In conclusion, cfChIP-seq of cfDNA present in cancer patients’ plasma has potential to provide valuable information on tumor specific transcriptional dynamics during treatment in NSCLC. Harnessing this information could enable earlier detection of resistance and guide treatment switching. Citation Format: Christoffer T. Maansson, Simone Stensgaard, Emma Pedersen, Anders Lade Nielsen, Peter Meldgaard, Boe Sandahl Sorensen. Investigating treatment response and resistance in non-small cell lung cancer patients through epigenetic profiling of plasma nucleosomes [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2026; Part 1 (Regular Abstracts); 2026 Apr 17-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2026;86(7 Suppl):Abstract nr 2600.

Abstract Introduction: Lung cancer remains the leading cause of cancer-related death worldwide. Although tyrosine kinase inhibitors (TKIs) have improved outcomes for EML4-ALK-positive non-small cell lung cancer (NSCLC), most patients experience disease progression. Understanding the clinical and molecular factors that drive resistance is essential for guiding more effective treatment strategies. Aim: To identify molecular features associated with treatment resistance and survival in patients receiving first-line alectinib or brigatinib. Patients and Methods: Seventy-two patients with EML4-ALK-positive NSCLC treated with first-line alectinib or brigatinib were included. Plasma samples were obtained at baseline, during treatment, and at disease progression. Circulating tumor DNA (ctDNA) was analyzed using cancer personalized profiling by deep sequencing (CAPP-seq) and the R/Bioconductor package, DNAfusion, recently developed in our lab. ctDNA features at progression and at baseline were correlated to time to progression (TTP) and overall survival (OS). Results: During a median follow-up of 27 months, 54% (39/72) of patients developed disease progression. ALK on-target resistance mutations at progression were observed exclusively in short EML4-ALK variants (40% vs 0% in long variants, p<0.05). Patients with short variants also had numerically shorter TTP (14 vs 35 months, p=0.12) and OS (38 months vs NE, p=0.16). Baseline ctDNA profiles were analyzed to assess associations with clinical outcomes. Patients with a high plasma mutation load (>1 mutation) had significantly shorter TTP (13 vs 51 months, p<0.05) and OS (36 months vs NE, p<0.05) compared with those with a low load (0-1 mutation). In addition, TP53 mutations were strongly associated with poor outcomes (TTP: 10 vs 45 months, p<0.05; OS: 12 months vs NE, p<0.05). Conclusion: Development of ALK on-target resistance mutations at progression demonstrates a significant association with short EML4-ALK variants. A high mutation load and TP53 mutations at baseline identify patients at risk of early progression and poor survival under second-generation ALK TKI treatment. These findings suggest that ctDNA-based molecular profiling may help guide personalized treatment strategies and improve survival outcomes for EML4-ALK-positive NSCLC. Citation Format: Emma Roger Sønderbek, Maiken Parm Ulhøi, Peter Meldgaard, Boe Sandahl Sorensen. Baseline ctDNA profiling identifies molecular predictors of resistance to second-generation ALK inhibitors in EML4-ALK-positive NSCLC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2026; Part 1 (Regular Abstracts); 2026 Apr 17-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2026;86(7 Suppl):Abstract nr 5309.

PURPOSE:Among responders to PD-1/PD-L1 blockade, it remains unclear whether tumour type and traditional baseline patient and tumour characteristics provide additional prognostic information for progression risk beyond response depth. METHODS:In this nationwide, population-based cohort study, we identified adults with metastatic melanoma (MM), renal cell carcinoma (RCC), or non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 monotherapy or dual checkpoint blockade. Analyses were restricted to responders by investigator-assessed RECIST (complete or partial response) with outcomes administratively censored at 5 years. Prespecified baseline and on-treatment variables were evaluated for associations with progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier and Cox models and assessed for consistency across tumour types. RESULTS:Among 2127 responders, PFS trajectories within response depth categories (complete response and partial response) were highly similar across MM, RCC, and NSCLC. Prespecified variables with prognostic value in the overall population, including performance status and treatment line, provided limited additional prognostic information once response depth was known. Depth of response (complete vs partial) was the strongest independent factor associated with progression risk within each tumour cohort. CONCLUSIONS:Among patients with MM, RCC, or NSCLC who achieved an objective response to PD-1/PD-L1 blockade, tumour type and traditional baseline prognostic factors provided limited additional stratification of progression risk once response depth was known. These findings suggest that, within the tumour types studied, response durability is primarily associated with response depth rather than other known clinical features, supporting prospective evaluation of response-guided follow-up strategies and interventions designed to deepen responses.

Disruptions in sleep and circadian rhythms have been consistently linked to higher mortality rates in the general population. Among cancer patients, these disruptions are not only prevalent but may significantly influence prognosis. Despite this, sleep and circadian trajectories remain unexplored in the context of cancer, particularly related to prognostic outcomes in modern therapies such as immune checkpoint inhibitors (ICIs), which are rapidly transforming oncological care. In this pioneering report, we examined how trajectories of sleep and circadian rhythms relate to prognostic outcomes in patients with non-small cell lung cancer (NSCLC), offering novel insights into their potential role as modifiable biomarkers of clinical outcomes. Forty-nine treatment-naïve NSCLC patients were enrolled in this prospective longitudinal study. Continuous 24-h recordings of circadian function (Circadian Function Index [CFI]) were collected over the first 5 months of treatment, alongside weekly assessments of insomnia severity (Insomnia Severity Index [ISI]) and estimations of total sleep time (TST) derived from sleep diaries every 3 weeks. Follow-up data, time to treatment discontinuation, disease progression, and cancer-related death were obtained from medical records. We estimated hazard ratios (HRs) for these outcomes based on ISI, TST, and CFI, analyzed as continuous variables and median-split. Cox regression analyses indicated that patients with trajectories portraying circadian robustness below the median had a higher risk of earlier progression (HR = 3.75, 95% confidence interval [CI] = [1.475-9.536], p = 0.005) and death (HR = 3.07, 95% CI = [1.128-8.360], p = 0.028). No significant associations were found between insomnia severity, TST, and the prognostic outcomes. Patients with more pronounced declines in circadian robustness demonstrated significantly elevated risks of disease progression and mortality. As the circadian rhythm is modifiable, these findings, if replicated, underscore the need for interventional studies aimed at stabilizing circadian rhythms to further explore potential improvements in patient outcomes and efficacy of cancer therapies.

PURPOSE:We investigated whether EML4-ALK fusions and mutations in pre-treatment plasma ctDNA predicted time to treatment discontinuation (TTD) in ALK-positive non-small cell lung cancer (ALK+ NSCLC) patients initiating first-line alectinib and evaluated clinical characteristics influencing TTD. MATERIALS & METHODS:42 patients from five Danish public oncology departments with previously untreated, metastatic ALK+ NSCLC were included in the study. All patients received alectinib, a second-generation ALK inhibitor, as their first-line treatment. Clinical characteristics were obtained from the patients' health records. Plasma samples were collected before treatment start and analyzed with next-generation sequencing (NGS) analysis with the AVENIO ctDNA Surveillance kit. RESULTS:We demonstrate that alectinib is effective regardless of baseline brain metastases, EML4-ALK variant type and co-mutations. The entire cohort had a median TTD for alectinib of 35.1 months (95% CI: 10.2-52). TTD for patients with baseline brain metastasis (BM) had a median of 34.4 months (95% CI:4.1- "not estimated" (NE)), whereas patients with no BM at baseline had a median of 16.9 months (95% CI: 4.6-NE). Additionally, 57% of the cohort were smokers, and the median TTD was shorter in smokers (11.2 months) than in never-smokers (52.0 months). CONCLUSION:In incurable ALK+ NSCLC, alectinib appears effective as first-line therapy regardless of brain metastases. EML4-ALK fusions occur in smokers, and smoking may reduce TTD. These findings, limited by the small cohort, require confirmation in larger studies but may still help guide treatment predictions and strategies.

Neoantigen vaccines are under investigation for various cancers, including epidermal growth factor receptor (EGFR)-driven lung cancers1,2. We tracked the phylogenetic history of an EGFR mutant lung cancer treated with erlotinib, osimertinib, radiotherapy and a personalized neopeptide vaccine (NPV) targeting ten somatic mutations, including EGFR exon 19 deletion (ex19del). The ex19del mutation was clonal, but is likely to have appeared after a whole-genome doubling (WGD) event. Following osimertinib and NPV treatment, loss of the ex19del mutation was identified in a progressing small-cell-transformed liver metastasis. Circulating tumour DNA analyses tracking 467 somatic variants revealed the presence of this EGFR wild-type clone before vaccination and its expansion during osimertinib/NPV therapy. Despite systemic T cell reactivity to the vaccine-targeted ex19del neoantigen, the NPV failed to halt disease progression. The liver metastasis lost vaccine-targeted neoantigens through chromosomal instability and exhibited a hostile microenvironment, characterized by limited immune infiltration, low CXCL9 and elevated M2 macrophage levels. Neoantigens arising post-WGD were more likely to be absent in the progressing liver metastasis than those occurring pre-WGD, suggesting that prioritizing pre-WGD neoantigens may improve vaccine design. Data from the TRACERx 421 cohort3 provide evidence that pre-WGD mutations better represent clonal variants, and owing to their presence at multiple copy numbers, are less likely to be lost in metastatic transition. These data highlight the power of phylogenetic disease tracking and functional T cell profiling to understand mechanisms of immune escape during combination therapies.

The genomic instability associated with cancer can result in the formation of extrachromosomal circular DNA (eccDNA), which contributes to tumor heterogeneity, gene amplification, tumor evolution, and drug resistance. However, most studies on eccDNA have been conducted on tumor tissue or cancer cell lines, and limited research has been done on eccDNA in plasma. In this study, we investigated eccDNA in non-small cell lung cancer (NSCLC) by sequencing plasma eccDNA from 32 epidermal growth factor receptor (EGFR)-mutated NSCLC patients before and during treatment with osimertinib, as well as plasma eccDNA from five healthy individuals. Plasma eccDNA was identified in all samples but with significantly higher levels in cancer patients than healthy controls. EGFR-overlapping eccDNA, eccDNA that contains part of or the whole EGFR gene, was detected in the majority of samples both at baseline and during treatment. High levels of EGFR-overlapping eccDNA during osimertinib treatment were associated with significantly shorter progression-free survival and overall survival. Plasma eccDNA represents a newly identified type of biomarker for monitoring treatment efficacy.

BACKGROUND:Circulating tumor DNA (ctDNA) has the potential to become a reliable biomarker for identifying minimal residual disease (MRD) and predicting recurrence in patients with non-small cell lung cancer (NSCLC) following curative treatment. However, there is a lack of studies that investigate the clinical validity of ctDNA using a tumor-agnostic approach, which can provide significant clinical benefits. METHODS:We analyzed samples from 45 NSCLC patients recruited in a prospective national multicenter study, all of whom had undergone curative treatment. A total of 38 pre-treatment plasma samples and 76 post-treatment plasma samples were examined using a commercially available cancer personalized profiling by deep sequencing (CAPP-seq) strategy, and a tumor-agnostic approach. Post-treatment samples were collected at two distinct landmark time points: Follow-up 1 (0.5-4.5 months post-treatment) and Follow-up 2 (4.5-7.5 months post-treatment). RESULTS:Detectable ctDNA post-treatment was significantly associated with increased risk of tumor recurrence and shorter recurrence-free survival (RFS). Using only a single blood sample taken from Follow-up 2, we correctly identified MRD in 50% of the patients who later experienced recurrence. However, subgroup analysis further revealed that in patients treated with radiotherapy or chemoradiotherapy (CRT), ctDNA detection was significantly linked to shorter RFS in the MRD analysis from Follow-up 2, but not in the MRD analysis from Follow-up 1. CONCLUSION:These findings suggest that post-treatment ctDNA, detected using a tumor-agnostic approach, is a reliable biomarker for predicting recurrence in NSCLC patients following curative treatment. However, the optimal timing for blood sampling to detect MRD appears to depend on the type of curative treatment received.

BACKGROUND:Patients with advanced non-small cell lung cancer (NSCLC) face poor prognosis. However, new therapies like immune checkpoint inhibitors (ICIs) have improved survival. Nevertheless, ICIs act through immune activation - a proposed underlying mechanism of frequently reported symptoms such as sleep and circadian disturbances. The objective of this study was to longitudinally investigate sleep and circadian rest-activity rhythms and associations with psychological symptoms in NSCLC during ICI treatment. METHODS:Newly diagnosed NSCLC patients were included in this prospective study, assessing insomnia severity, total sleep time, circadian rest-activity rhythms, and psychological symptoms (fatigue, depression, and stress) during the first five months of ICI treatment, using validated questionnaires, sleep diaries and actigraphy. RESULTS:Forty-nine patients were included. Prior to treatment, patients slept on average 5.8 hours/night and 49 % reported clinical levels of insomnia. Spontaneous improvements in insomnia severity and total sleep time were observed, along with marginal but non-significant improvements in circadian rest-activity rhythm robustness. Insomnia severity was significantly associated with higher levels of fatigue (p = .004), depression (p = .007), and perceived stress (p = .033). Moreover, lower circadian rest-activity robustness was associated with more fatigue (p = .021). At baseline, mean levels of fatigue, depression, and perceived stress were below clinical levels and declined further over time. CONCLUSION:Sleep disturbances, circadian disruption, and psychological symptom burden in NSCLC patients were greatest prior to and shortly after initiation of ICI treatment, with gradual improvement over the first five months. However, inter-individual differences in sleep and circadian disturbances were evident and linked to psychological symptoms.

Osimertinib (AZD9291) is a widely used tyrosine kinase inhibitor for the treatment of non-small cell lung cancer patients with activating EGFR mutations. However, the correlation between dose and efficacy has been debated for several years. For this reason, there is a need for standardized methods for routine analysis, clinical studies on pharmacokinetics and dose-response relationships, and greater understanding of preanalytical conditions, such as sample storage stability. The objective of this study was to develop and validate a sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for simultaneous quantification of osimertinib and its two metabolites, AZ7550 and AZ5104, in human plasma and to investigate long-term storage stability of the analytes. Samples were prepared by protein precipitation and separated on a Kinetex EVO C18 column (2.1 x 150 mm, 2.6 mu m). Electrospray ionization in positive mode and multiple reaction monitoring were used to monitor the ion transitions. The validated concentration ranges were from 1.25 to 3000 ng/mL. Interassay precisions and accuracies were all <= 15 %. Linearity, dilution integrity, and carry-over were also examined and satisfied the validation criteria. Stability was examined under different conditions, and the analytes were found to be stable for more than 3 years at-80(degrees)C (< 15 % decline). Finally, the analytical method was successfully applied in a clinical setting on plasma samples from 30 patients with non-small cell lung cancer in treatment with osimertinib, demonstrating its suitability for use in clinical studies and its potential for therapeutic drug monitoring.

Introduction: Recent studies have demonstrated differences between the fragment length profiles of cell-free DNA (cfDNA) from cancer patients and healthy individuals. This has led to the development of in vitro size-selection procedures which can isolate the short fragments that are enriched with mutated circulating tumor DNA (ctDNA). This has yet to be investigated in a large cohort of lung cancer patients. Materials and methods: We used plasma samples from 35 stage III and IV lung cancer patients and performed targeted next-generation sequencing (NGS) and variant calling from cfDNA with and without size-selection of short fragments. We identified clonal hematopoiesis (CH) and germline mutations using targeted NGS on paired buffy coat (BC) samples. In addition, we performed a genome-wide copy-number alteration analysis on the cfDNA samples with and without size-selection. Results: ctDNA containing tumor mutations had a different fragment length profile compared to cfDNA fragments with CH or germline mutations. In vitro size-selection resulted in a median 1.36-fold (interquartile range (IQR): 0.63 to 2.48) mutational allele fraction (MAF) enrichment of tumor mutations whereas CH/germline mutations had a median 0.95-fold (IQR: 0.62 to 1.05) MAF enrichment. Key oncogenic drivers, including KRAS and EGFR were more likely to have a MAF increase with size-selection. Size-selection also increased the number plasma aneuploidy positive samples from 8 of 35 to 20 of 35. Conclusion: This study expands the knowledge regarding ctDNA fragmentation in lung cancer patients and we demonstrate that in vitro size-selection can increase MAF of tumor mutations and plasma aneuploidy calls. Size-selection could lead to increased sensitivity of ctDNA detection, which is crucial for clinical implementation of liquid biopsies. This study is the largest of its kind studying cfDNA samples from 35 lung cancer patients containing 109 mutations in total.

Multiple studies have shown that cell-free DNA (cfDNA) from cancer patients differ in both fragment length and fragment end motif (FEM) from healthy individuals, yet there is a lack of understanding of how the two factors combined are associated with cancer and gene transcription. In this study, we conducted cfDNA fragmentomics evaluations using plasma from lung cancer patients (n = 12) and healthy individuals (n = 7). A personal gene expression profile was established from plasma using H3K36me3 cell-free chromatin immunoprecipitation sequencing (cfChIP-seq). The genes with the highest expression displayed an enrichment of short cfDNA fragments (median = 19.99%, IQR: 16.94-27.13%, p < 0.0001) compared to the genes with low expression. Furthermore, distinct GC-rich FEMs were enriched after cfChIP. Combining the frequency of short cfDNA fragments with the presence of distinct FEMs resulted in an even further enrichment of the most expressed genes (median = 37.85%, IQR: 30.10-39.49%, p < 0.0001). An in vitro size selection of <150 bp cfDNA could isolate cfDNA representing active genes and the size-selection enrichment correlated with the cfChIP-seq enrichment (Spearman r range: 0.499-0.882, p < 0.0001). This study expands the knowledge regarding cfDNA fragmentomics and sheds new light on how gene activity is associated with both cfDNA fragment lengths and distinct FEMs.

ObjectivesVenous thromboembolism (VTE) is a common complication in patients starting cancer therapies for non-small cell lung cancer (NSCLC). We examined the risk and timing of VTE in patients with stage IIIA, IIIB-C, and stage IV NSCLC according to received cancer treatments.Materials and MethodsA nationwide registry-based cohort study of patients recorded in the Danish Lung Cancer Registry (2010-2021) followed for 1 year after entry into the registry to assess the incidence of VTE. The Aalen-Johansen estimator was used to calculate the risk of VTE after treatment commencement with chemotherapy, radiotherapy, chemoradiation, immunotherapy, and targeted therapy.ResultsAmong the 3,475 patients with stage IIIA, 4,047 with stage IIIB-C, and 18,082 patients with stage IV cancer, the 1-year risk of VTE was highest in the first six months and varied markedly by cancer stage and cancer treatment. In stage IIIA, VTE risk was highest with chemotherapy (3.9%) and chemoradiation (4.1%). In stage IIIB-C, risks increased with chemotherapy (5.2%), immunotherapy (9.4%) and targeted therapy (6.0%). Stage IV NSCLC showed high risk with targeted therapy (12.5%) and immunotherapy (12.2%). The risk was consistently higher for pulmonary embolism than deep vein thrombosis.ConclusionVTE risks vary substantially according to cancer treatments and cancer stages. The highest risk was observed in the initial six months of therapy initiation. These insights emphasize the need for tailored risk assessment and vigilance in managing VTE complications in patients with NSCLC. Further research is needed to optimize individual thromboprophylaxis strategies for patients with unresectable and metastatic NSCLC.Micro abstractThis nationwide cohort study highlights the significant risk of VTE in patients undergoing cancer therapies for NSCLC. The 1-year risk of VTE was highest within the initial six months of treatment and demonstrated substantial variability on cancer stage and the specific treatments received.These findings emphasize the importance of a nuanced risk assessment tailored to both cancer stage and the specific cancer therapies employed. Such insights contribute to the ongoing efforts to optimize patient care.

OBJECTIVES: Venous thromboembolic event (VTE) is a severe complication in patients with lung cancer undergoing thoracic surgery. Nevertheless, because of insufficient evidence, there are no clear guidelines, and VTE prophylaxis practices vary widely. This nationwide cohort study was a comparative study investigating VTE risk in surgical departments that routinely administered in-hospital thromboprophylaxis with low-molecular-weight heparin compared to those that did not. METHODS: We identified all patients with non-small-cell lung cancer (NSCLC) who underwent surgery in Denmark during 2010-2021. Thoracic surgery was exclusively performed in the 4 university hospitals. Three hospitals implemented in-hospital thromboprophylaxis as standard care since 2000, while the fourth adopted this practice in September 2016. VTE events were assessed at 6-month follow-up according to hospital and study period, using an inverse probability of treatment weighting approach. RESULTS: We identified 9615 patients. During 6-month follow-up, a total of 190 VTE events were observed, resulting in a weighted rate of 4.5 events per 100 person-years and an absolute risk of 2.2%. There was no clear trend according to hospital site or use of in-hospital thromboprophylaxis with a 2.2% risk in the hospital not using thromboprophylaxis compared to 1.7-3.1% in those that did. CONCLUSIONS: Use of in-hospital thromboprophylaxis did not affect the risk of VTE after surgery for NSCLC, suggesting that relying solely on in-hospital thromboprophylaxis may be insufficient to mitigate VTE risk in these patients. Further research is warranted to investigate the potential benefits of extended thromboprophylaxis in reducing VTE risk in selected NSCLC surgical patients.

BACKGROUND Venous thromboembolism (VTE) is a potentially preventable serious complication in patients with lung cancer undergoing thoracic operation. We examined the risk and timing of VTE after surgery for primary non -small cell lung cancer (NSCLC). METHODS All patients undergoing operation for NSCLC in Denmark between 2003 and 2021 were identified in the Danish Lung Cancer Registry. VTE events in the year after operation were assessed by stage, patient characteristics, and surgical procedure. RESULTS We identified 13,197 patients who underwent operation for NSCLC in 2003 to 2021 (mean age, 67.6 years; 50% female); 10,524 (79.7%) had stage I -II NSCLC, and 2673 (20.3%) had stage III -IV. During 1 -year follow-up, there were 335 VTE events, yielding a rate of 2.87 events/100 person -years and an absolute risk of 3.3% (95% CI, 2.3-4.0). VTE risk increased with advancing cancer stage (1.8% for stage I vs 3.9% for stage IV) but varied little by pathologic type, sex, and comorbidity level. Bilobectomy was associated with highest VTE risk (4.8%; 95% CI, 3.2-6.9), followed by pneumonectomy (3.5%; 95% CI, 2.3-5.0). The hazard of VTE was highest during the first 3 months after operation, after which it declined. For stage IV cancer, hazards increased again after 6 months. At 1 year, all -cause death was 12.6% (95% CI, 12.0%-13.1%). CONCLUSIONS VTE developed in 3.3% of patients undergoing operation for NSCLC, most commonly within 3 months postoperatively. Prolonged thromboprophylaxis could be considered, particularly in those with advanced cancer stage and undergoing extended resections. (Ann Thorac Surg 2024;117:289-96) (c) 2024 by The Society of Thoracic Surgeons. Published by Elsevier Inc.

AimsThe aim of this study was to investigate the association between oncogenic alterations and programmed cell death ligand 1 (PD-L1) expression in lung adenocarcinomas, as well as the prognostic value ofKRASand/orTP53mutations in patients treated with immunotherapy.MethodsThis study is a retrospective cohort study of 519 patients with lung adenocarcinomas analysed for mutations and PD-L1 expression. Data were collected from electronic pathology record system, next-generation sequencing system, and clinical databases. Association between mutations and PD-L1 expression was investigated, as well as survival statistics of the 65 patients treated with immunotherapy.Results41% of the samples contained aKRASmutation, predominantly together with mutations inTP53(41%) orSTK11(10%). Higher expression of PD-L1 was seen among patients withKRASmutations (p=0.002) andEGFRwild type (p=0.006). For patients treated with immunotherapy, there was no statistically significant difference for overall survival (OS) and progression-free survival (PFS) according toKRASmutation status,TP53mutation status or PD-L1 expression. The HR for concomitant mutations inTP53andKRASwas 0.78 (95% CI 0.62 to 0.99) for OS and 0.43 (0.21 to 0.88) for PFS. Furthermore, concomitantTP53andKRASmutations predicted a better PFS (p=0.015) and OS (p=0.029) compared with no mutations or a single mutation in eitherTP53orKRAS.ConclusionMutations inTP53together withKRASmay serve as a potential biomarker for survival benefits with immunotherapy.

Survival rates in non-small cell lung cancer (NSCLC) are low. Detection of circulating tumor DNA in liquid biopsy (plasma) is increasingly used to identify targeted therapies for clinically actionable mutations, including EGFR mutations in NSCLC. The cobas® EGFR Mutation Test v2 (cobas EGFR test) is FDA-approved for EGFR mutation detection in tissue or liquid biopsy from NSCLC. Standard K2EDTA tubes require plasma separation from blood within 4 to 8 hours; however, Roche Cell-Free DNA (cfDNA) Collection Tubes (Roche cfDNA tube) enable whole blood stability for up to 7 days prior to plasma separation. This analysis assessed performance of Roche cfDNA tubes with the cobas EGFR test for the detection of EGFR mutations in plasma from healthy donors or patients with NSCLC. Overall, test performance was equally robust with either blood collection tube, eg, regarding limit of detection, linearity, and reproducibility, making Roche cfDNA tubes suitable for routine clinical laboratory use in this setting. Importantly, the Roche cfDNA tubes provided more flexibility for specimen handling versus K2EDTA tubes, eg, in terms of tube mixing, plasma separation, and sample stability, and do not require processing of blood within 8 hours thereby increasing the reach of plasma biopsies in NSCLC.