Ming Tsao

IntroductionMorphologic and molecular data for staging of multifocal lung squamous cell carcinomas (LSCCs) are limited. In this study, whole exome sequencing (WES) was used as the gold standard to determine whether multifocal LSCC represented separate primary lung cancers (SPLCs) or intrapulmonary metastases (IPMs). Genomic profiles were compared with the comprehensive morphologic assessment.MethodsWES was performed on 20 tumor pairs of multifocal LSCC and matched normal lymph nodes using the Illumina NovaSeq6000 S4-Xp (Illumina, San Diego, CA). WES clonal and subclonal analysis data were compared with histologic assessment by 16 thoracic pathologists. In addition, the immune gene profiling of the study cases was characterized by the HTG EdgeSeq Precision Immuno-Oncology Panel.ResultsBy WES data, 11 cases were classified as SPLC and seven cases as IPM. Two cases …

In the published version of this paper, the members of the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium were listed in the Supplementary Information; however, these members should have been included in the main paper. The original Article has been corrected to include the members and affiliations of the PCAWG Consortium in the main paper; the corrections have been made to the HTML version of the Article but not the PDF version. Additional minor corrections to affiliations have been made to the PDF and HTML versions of the original Article for consistency of information between the PCAWG list and the main paper.

The Canadian NTRK (CANTRK) study is an interlaboratory comparison ring study to optimize testing for neurotrophic receptor tyrosine kinase (NTRK) fusions in Canadian laboratories. Sixteen diagnostic laboratories used next-generation sequencing (NGS) for NTRK1, NTRK2, or NTRK3 fusions. Each laboratory received 12 formalin-fixed, paraffin-embedded tumor samples with unique NTRK fusions and two control non-NTRK fusion samples (one ALK and one ROS1). Laboratories used validated protocols for NGS fusion detection. Panels included Oncomine Comprehensive Assay v3, Oncomine Focus Assay, Oncomine Precision Assay, AmpliSeq for Illumina Focus, TruSight RNA Pan-Cancer Panel, FusionPlex Lung, and QIAseq Multimodal Lung. One sample was withdrawn from analysis because of sample quality issues. Of the remaining 13 samples, 6 of 11 NTRK fusions and both control fusions were detected …

We employ wide‐field second harmonic generation (SHG) microscopy together with nonlinear Stokes polarimetry for quick ultrastructural investigation of large sample areas (700 μm × 700 μm) in thin histology sections. The Stokes vector components for SHG are obtained from the polarimetric measurements with incident and outgoing linear and circular polarization states. The Stokes components are used to construct the images of polarimetric parameters and deduce the maps of ultrastructural parameters of achiral and chiral nonlinear susceptibility tensor components ratios and cylindrical axis orientation in fibrillar materials. The large area imaging was employed for lung tumor margin investigations. The imaging shows reduced SHG intensity, increased achiral susceptibility ratio values, and preferential orientation of collagen strands along the boarder of tumor margin. The wide‐field Stokes polarimetric SHG …

Methods: Patients with clinical T< 4cm N0 NSCLC planned for surgical resection at Princess Margaret/University Health Network underwent plasma ctDNA assessment before and after surgery (∼ 1 month and 1 year). Minimal residual disease (MRD) was detected using the highly sensitive and specific tumor-informed RaDaR® assay (NeoGenomics, Durham, NC), testing up to 48 tumor-specific variants in plasma with a limit of detection 95 of 0.0011% variant allele fraction.Results: From Aug 2021-Feb 2023, 129 patients were enrolled and 70 had sufficient tissue for ctDNA bespoke panel generation (Table 1). Preoperative ctDNA was detected in 17/69 (24.6%) patients (with a lower detection rate of 9/50 or 18% in pathologic stage I NSCLC). All but one patient (1/17; 94.1%) had ctDNA clearance with surgery at 1-month landmark timepoint. This patient with occult N2 disease remains disease-free radiographically on …

The high expression of epidermal growth factor receptor (EGFR) in carcinomas from multiple tissue sites led to preclinical studies and early trials assessing the efficacy of EGFR inhibitors in multiple cancer types. In these early studies, one class of EGFR inhibitors that targets the tyrosine kinase domain of the receptor proved effective in some patients with lung adenocarcinoma. It was later shown that mutations in the tyrosine kinase (TK) domain rather than the EGFR expression predicted response to this class of drugs. First-, second-, and third-generation EGFR TKIs (tyrosine kinase inhibitors) were successively developed and became the standard of care in the treatment of patients with EGFR-mutated lung cancer. Despite the improvements in survival achieved by these drugs, patients still face challenges as mechanisms of resistance eventually develop and lead to disease progression. This chapter will outline …

Colorectal cancer is the third most common cancer and the second leading cause of cancer-related deaths worldwide. The centrosome is the main microtubule-organizing center in animal cells and centrosome amplification is a hallmark of cancer cells. To investigate the importance of centrosomes in colorectal cancer, we induced centrosome loss in normal and cancer human-derived colorectal organoids using centrinone B, a Polo-like kinase 4 (Plk4) inhibitor. We show that centrosome loss represses human normal colorectal organoid growth in a p53-dependent manner in accordance with previous studies in cell models . However, cancer colorectal organoid lines exhibited different sensitivities to centrosome loss independently of p53. Centrinone-induced cancer organoid growth defect/death positively correlated with a loss of function mutation in the APC gene, suggesting a causal role of the hyperactive WNT pathway. Consistent with this notion, β-catenin inhibition using XAV-939 or ICG-001 partially prevented centrinone-induced death and rescued the growth of APC-mutant organoid lines. Our study reveals a novel role for canonical WNT signaling in regulating centrosome loss-induced growth defect/death in APC-mutant colorectal cancer independently of the classical p53 pathway.

Introduction: Patients with early-stage lung cancers have a high risk of relapse and death even after curative surgery. Detection of circulating tumour DNA (ctDNA) in plasma perioperatively is associated with shorter recurrence free survival (RFS). ctDNA-Lung-Detect is an investigator-initiated prospective study of ctDNA detection and association with RFS in patients with early stage non-small cell lung cancer (NSCLC). Methods: Patients with clinically staged T<4cm N0 NSCLC planned for surgical resection at the Princess Margaret/University Health Network underwent ctDNA assessment before and after surgery (~1 month and 1 year). ctDNA minimal residual disease (MRD) was detected using the highly sensitive and specific tumor-informed Residual Disease and Recurrence (RaDaR®, Inivata, Cambridge, UK) assay, which can track up to 48 tumor-specific variants in plasma. Results: Since August 2021, 64 …

Methods: We analyzed the negative predictive value of plasma ctDNA testing (InVision First Lung, Inivata) in patients with advanced non-squamous NSCLC in the ACCELERATE cohort.Results: Of 90 patients with advanced non-squamous NSCLC that underwent plasma testing, 46 (51%) had Tier1 actionable drivers identified in plasma, 30 patients (33%) had non-actionable alterations, and 14 (16%) had no detectable ctDNA. Non-actionable alterations included KRAS non-G12C (n= 9), STK11 (n= 4), PIK3CA, PTEN mutations (1 each), ERBB2, MET or FGFR amplification (1 each) and TP53 mutations (12 isolated, 11 co-altered with other non-actionable alterations). Only one patient with a non-actionable mutation in plasma (TP53) had a driver alteration identified in tissue (ALK fusion). Of 14 patients with undetectable cfDNA in plasma, 6 had actionable alterations found in tissue (4 EGFR activating mutations, 2 ALK …

AimsAccelerated hypofractionated radiotherapy is used at our institution for non-small cell lung cancer (NSCLC) patients not eligible for stereotactic body radiotherapy or chemoradiotherapy. The purpose of this study was to report clinical outcomes of delivering 60 Gy in 15 fractions for these patients.Materials and MethodsAll NSCLC patients who received 60 Gy in 15 fractions were reviewed. Outcomes of interest were local failure, regional failure, distant progression, overall survival and treatment-associated toxicities.ResultsIn total, 111 patients were included. The median age was 78.8 years and most tumours were adenocarcinoma (n = 55, 49.6%). Sixty-five patients (58.6%) were N0. The cumulative incidence of local failure at 12 and 24 months in the N0 cohort was 5.2% and 14.2%, respectively, compared with 11.5% and 14.8% for N+ patients. Tumour size >35 mm predicted for local failure (hazard ratio 2.706 …

IntroductionTargeted therapies require life-long treatment, as drug discontinuation invariably leads to tumor recurrence. Recurrence is mainly driven by minor subpopulations of drug-tolerant persister (DTP) cells that survive the cytotoxic drug effect. In lung cancer, DTP studies have mainly been conducted with cell line models.MethodsWe conducted an in vivo DTP study using a lung adenocarcinoma patient-derived xenograft tumor driven by an EGFR mutation. Daily treatment of tumor-bearing mice for 5 to 6 weeks with the EGFR inhibitor erlotinib markedly shrunk tumors and generated DTPs, which were analyzed by whole exome, bulk population transcriptome, and single-cell RNA sequencing.ResultsThe DTP tumors maintained the genomic clonal architecture of untreated baseline (BL) tumors but had reduced proliferation. Single-cell RNA sequencing identified a rare (approximately 4%) subpopulation of BL …

MethodsConsenting patients with radiologic evidence of advanced lung cancer referred to the University Health Network Lung Rapid Diagnostic Program underwent circulating tumor DNA (ctDNA) testing with InVisionFirst®-Lung, a next-generation sequencing assay (NGS) on plasma collected during the diagnostic work up. Tumor tissue was tested by comprehensive NGS (Oncomine™). The primary endpoint was time from referral to treatment in advanced non-squamous (nonsq) NSCLC patients compared to a recent historical cohort (N= 89).ResultsBetween July 1, 2021 and November 30, 2022, 150 patients were enrolled. 90 patients (60%) had advanced nonsqNSCLC. The median time to treatment was 39 days with plasma-first (IQR 27-52) versus 62 days (IQR 44-82) in the historical cohort, p< 0.001. The median turnaround time from sample collection to molecular results was 7 days for plasma (IQR 6-9) and …

The introduction of high-throughput sequencing technologies has allowed for comprehensive RNA species detection, both coding and non-coding, which opened new avenues for the discovery of predictive and prognostic biomarkers. However the consistency of the detection of different RNA species depends on the RNA selection protocol used for RNA-sequencing. While preliminary reports indicated that non-coding RNAs, in particular circular RNAs, constitute a rich source of biomarkers predictive of drug response, the reproducibility of this novel class of biomarkers has not been rigorously investigated. To address this issue, we assessed the inter- lab consistency of circular RNA expression in cell lines profiled in large pharmacogenomic datasets. We found that circular RNA expression quantified from rRNA-depleted RNA-seq data is stable and yields robust prognostic markers in cancer. On the other hand, quantification of the expression of circular RNA from poly(A)-selected RNA-seq data yields highly inconsistent results, calling into question results from previous studies reporting their potential as predictive biomarkers in cancer. We have also identified median expression of transcripts and transcript length as potential factors influencing the consistency of RNA detection. Our study provides a framework to quantitatively assess the stability of coding and non-coding RNA expression through the analysis of biological replicates within and across independent studies.

IntroductionSince the eight edition of the Union for International Cancer Control and American Joint Committee on Cancer TNM classification system, the primary tumor pT stage is determined on the basis of presence and size of the invasive components. The aim of this study was to identify histologic features in tumors with lepidic growth pattern which may be used to establish criteria for distinguishing invasive from noninvasive areas.MethodsA Delphi approach was used with two rounds of blinded anonymized analysis of resected nonmucinous lung adenocarcinoma cases with presumed invasive and noninvasive components, followed by one round of reviewer de-anonymized and unblinded review of cases with known outcomes. A digital pathology platform was used for measuring total tumor size and invasive tumor size.ResultsThe mean coefficient of variation for measuring total tumor size and tumor invasive …

MethodsA Data Collection Survey collected aggregate monthly enrollment numbers from 294 global lung cancer trials for 2019-2020. A 64-question Action Survey assessed the impact of COVID-19 on clinical trials and identified mitigation strategies implemented.

The ability of a patient tumor to engraft an immunodeficient mouse is the strongest known independent indicator of poor prognosis in early-stage non–small cell lung cancer (NSCLC). Analysis of primary NSCLC proteomes revealed low-level expression of mitochondrial aconitase (ACO2) in the more aggressive, engrafting tumors. Knockdown of ACO2 protein expression transformed immortalized lung epithelial cells, whereas upregulation of ACO2 in transformed NSCLC cells inhibited cell proliferation in vitro and tumor growth in vivo. High level ACO2 increased iron response element binding protein 1 (IRP1) and the intracellular labile iron pool. Impaired cellular proliferation associated with high level ACO2 was reversed by treatment of cells with an iron chelator, whereas increased cell proliferation associated with low level ACO2 was suppressed by treatment of cells with iron. Expression of …

Background Lung squamous cell carcinoma (LUSC) currently has limited therapeutic options because of the relatively few validated targets and the lack of clinical drugs for some of these targets. Although NRF2/NFE2L2 pathway activation commonly occurs in LUSC, NRF2 has predominantly been studied in other cancer models. Here, we investigated the function of NRF2 in LUSC, including in organoid models, and we explored the activity of a small molecule NRF2 inhibitor ML385, which has not previously been investigated in LUSC. Methods We first explored the role of NRF2 signaling in LUSC cancer cell line and organoid proliferation through NRF2 knockdown or ML385 treatment, both in vivo and in vitro. Next, we performed Western blot and immunofluorescence assays to determine the effect of NRF2 inhibition on PI3K‐mTOR signaling. Finally, we used cell viability and clonogenic assays to explore …

Immune checkpoint inhibitors have activity in mesothelioma. IND.227 was a phase 2 trial (120 patients planned) comparing progression-free survival of standard platinum and pemetrexed (CP) versus CP + pembrolizumab (pembro) versus pembro. Accrual to the pembro arm was discontinued on the basis of interim analysis (IA—16 wk disease control rate). CP + pembro was tolerable, with progression-free survival similar between arms and median survival and overall response rate higher than those of CP alone (19.8 mo [95% confidence interval or CI: 8.4–41.36] versus 8.9 mo [95% CI: 5.3–12.8] and 47% [95% CI: 24%–71%] versus 19% [95% CI: 5%–42%], respectively). The subsequent phase 3 trial has completed accrual; results are expected in 2023.

Substantial changes in the 2021 WHO Classification of Tumors of the Pleura and Pericardium since the 2015 WHO Classification include the following: (1) pleural and pericardial tumors have been combined in one chapter whereas in the 2015 WHO, pericardial tumors were classified with cardiac tumors; (2) well-differentiated papillary mesothelioma has been renamed well-differentiated papillary mesothelial tumor given growing evidence that these tumors exhibit relatively indolent behavior; (3) localized and diffuse mesothelioma no longer include the term “malignant” as a prefix; (4) mesothelioma in situ has been added to the 2021 classification because these lesions can now be recognized by loss of BAP1 and/or MTAP by immunohistochemistry and/or CDKN2A homozygous deletion by fluorescence in situ hybridization; (5) the three main histologic subtypes (i.e., epithelioid, biphasic, and sarcomatoid) remain …

Hypoxia is present in most solid tumours and has been clinically correlated with poor prognosis, aggressive disease, and resistance to therapy in multiple cancer including pancreatic ductal adenocarcinoma (PDAC). It has been shown PDAC hypoxia levels are highly heterogeneous and that patient-derived-xenografts (PDXs) of PDAC have similar histological phenotypes including hypoxia to their matching primary tumours. This suggests a strong genetic determinant may underlie variations in tumour hypoxia and it is not simply the result of random events of angiogenesis. We hypothesize the steady state levels of hypoxia across patient tumours is also influenced by tumour specific differences in oxygen metabolism and tolerance to hypoxia. Genetic driven changes in cellular metabolism influence the demand for oxygen, which defines the levels and steepness of hypoxia gradients around perfused vessels …

Purpose/Objective(s)With the increasing utilization of stereotactic body radiation therapy (SBRT) for primary and metastatic cancer, use of multi-target thoracic (MTT) SBRT is rising. Given the limited safety and efficacy data on MTT, the purpose of this study was to report the experience of this strategy from a large academic center.Materials/MethodsBetween 2012 and 2021, patients who received SBRT for ≥2 thoracic targets within 1 year were retrospectively reviewed. The primary endpoint was clinically significant radiation pneumonitis (CSRP) requiring steroids, oxygen, or intubation. Secondary endpoints included late grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0) apart from pneumonitis, local failure (LF), initiation or change of systemic therapy (ICST), progression-free survival (PFS), and overall survival (OS). Competing risk analysis was used to evaluate the cumulative …

ObjectivesStandard molecular testing for patients with stage IV non-small cell lung cancer (NSCLC) in the Canadian publicly funded health system includes single gene testing for EGFR, ALK, and ROS-1. Comprehensive genomic profiling (CGP) may broaden treatment options for patients. This study examined the impact of CGP in a publicly funded health system.MethodsConsenting patients with stage IV NSCLC without known targetable alterations underwent CGP on diagnostic samples. Patients that had progressed on targeted therapy were also eligible. The CGP assay was a hybrid capture next generation sequencing (NGS) panel (Oncomine Comprehensive Assay Version 3, ThermoFisher). The number of actionable alterations, changes in treatment, clinical trial eligibility and costs as a result of CGP were evaluated and patient willingness-to-pay.ResultsOf 182 screened patients,134 (74%) had successful …

The current management of locally-advanced esophageal adenocarcinoma (EAC) includes neoadjuvant therapy; however, there are no robust markers that predict treatment response. While 25% of patients will have a complete pathological response, up to 40% will have little or no response. Identification of this non-responsive subgroup prior to treatment could allow personalization of induction regimens. This study aims to determine the feasibility of using patient-derived organoids (PDOs) generated from EAC to predict induction treatment response. PDOs were generated from endoscopic biopsies taken pre-treatment in patients with locally advanced (LA) or metastatic (M) esophageal cancer. For those with LA disease, samples were also taken post-resection. PDOs were established, passaged, then treated with a drug panel of platinum-based drugs, taxane-based drugs, topoisomerase inhibitors and 5 …

Immunotherapy including immune checkpoint inhibitors (ICIs) has become the backbone of treatment for most lung cancers with advanced or metastatic disease. In addition, they have increasingly been used for early stage tumors in neoadjuvant and adjuvant settings. Unfortunately, however, only a subset of patients experiences meaningful response to ICIs. Although programmed death-ligand 1 (PD-L1) protein expression by immunohistochemistry (IHC) has played a role as the principal predictive biomarker for immunotherapy, its performance may not be optimal, and it suffers multiple practical issues with different companion diagnostic assays approved. Similarly, tumor mutational burden (TMB) has multiple technical issues as a predictive biomarker for ICIs. Now, ongoing research on tumor- and host immune-specific factors has identified immunotherapy biomarkers that may provide better response and …

INTRODUCTION: CRISPR functional genomic screens have been widely adopted to identify essential genes and potential drug targets in cell line models. However, it is well known that cell line models studied in vitro do not fully capture the biology in patient tumors due to the lack of the tumor microenvironment. The primary objective of this study was to perform functional genomic screens in in vivo models to identify clinically relevant epigenetic vulnerabilities. METHODS: We designed an EpiDrug sgRNA library that target 357 epigenetic regulators in human, and applied this targeted sgRNA library for essentiality screen in 2D cell culture and 3D xenograft models. We subsequently selected targets that can only be identified in vivo for validation. We also investigated the underlying mechanism of the in vivo specific phenotype caused by target knockouts. Finally, we explored the clinical significance of treating …

The WHO classification system of tumors is adopted worldwide and is fundamental to how tumor or tumor-like conditions are clinically managed or treated. It is considered the international accepted standard for the diagnosis of tumors for clinical care of patients and education and research into the etiology, prevention, and treatment of cancers. The International Agency for Research on Cancer (IARC) has been responsible for the publication of the WHO classification of tumors books, often known as the Blue Book, since the third edition of the WHO Classification of Tumors of the Lung, Pleura, Thymus, and Heart was published in 2004, 1 and the fourth edition in 2015. 2The fifth edition of the WHO Classification book on Thoracic Tumors was published in April 2021. 3 In addition to a printed book, there is an online version that includes not only text, tables, and figures, but also whole-slide images (https …

MethodsA Delphi approach was used with two rounds of blinded anonymized analysis of resected non-mucinous lung adenocarcinoma cases with presumed invasive and non-invasive components including a subset of cases with known outcomes. This was followed by one round of reviewer de-anonymized and unblinded review of cases with known outcomes. A digital pathology platform was used for measuring total tumor size and invasive tumor size. Validation of the proposed criteria was performed on a set of 43 static images.ResultsThe mean coefficient of variation for measuring total tumor size and tumor invasive size was 6.9%(range 1.7-22.3%) and 54%(range 14.7-155%), respectively, with substantial variations in interpretation of the size and location of invasion among pathologists. A panel of 10 pathologists reviewed the results including unblinded re-evaluation of the images focused on cases with …

The tumor microenvironment, including cancer-associated fibroblast (CAF), plays an active role in non-small cell lung cancer (NSCLC) development and progression. We previously reported that collagen type XI and integrin α11, a collagen receptor, were upregulated in NSCLC; the latter promotes tumor growth and metastasis. We here explored the role of collagen type XI in NSCLC stroma. We showed that the presence of collagen type XI in collagen type I matrices inhibits CAF-mediated collagen remodeling and cell migration. This resulted in the inhibition of CAF-dependent lung-tumor cell invasion. Among the collagen receptors expressed on CAF, we determined that DDR2 and integrin α2β1, but not integrin α11β1, mediated the high-affinity binding to collagen type XI. We further demonstrated that collagen type XI restrained the integrin binding site availability on collagen type I matrices, thus limiting cell interaction with collagen type I. As a consequence, CAFs failed to activate FAK, p38 and Akt one hour after they interacted with collagen type I/XI. We concluded that collagen type XI may have a competitive negative feedback role on the binding of collagen type I to its receptors.

Purpose/Objective(s)Consolidation with Durvalumab is the standard of care in unresectable Stage 3 Non-Small Cell Lung cancer (NSCLC) following radical chemoradiation and pneumonitis is an independent side effect of these therapies. Literature has shown the peak time to development of radiation pneumonitis is 4-8 weeks. The purpose of this study was to describe the timing of radiation pneumonitis (RP) by receipt of Durvalumab in patients who received definitive chemoradiation.Materials/MethodsIn this single institution retrospective study, consecutive patients between 2016 and 2018 with unresectable Stage 3 treated with radical chemoradiation or radical chemoradiation followed by durvalumab were evaluated for development of at least grade 2 radiation pneumonitis based on clinical symptoms and characteristic radiology features. Descriptive analysis including the time from last fraction of radiotherapy …

organoid cultures derived from primary patient tumors and PDXs of various cancers including the colon, pancreas, prostate, liver and breast have been described (7, 8, 9, 10, 11, 12, 13, 14, 15, 16). These cancer organoids have been utilized for numerous applications, such as drug screening and biomarker identification (17, 18, 19, 20). They have been proposed to be better in vitro models than 2D cell lines due to higher rates of preservation of key histological and molecular traits of their parental tumors (14, 15). Additionally, drug screening in patient-derived organoids has shown high concordance with that of the matched patient tumor (14, 18). Some reports have demonstrated the ability to generate normal lung organoids composed of airway cell lineages (21, 22).

9128Background: Precision medicine has resulted in improved outcomes for non-small cell lung cancer (NSCLC); while molecular testing is considered critical for guiding treatment decisions for advanced stage NSCLC, adoption of testing in routine practice is variable. We analyzed the factors contributing to molecular testing and treatment patterns in patients with lung cancer. Methods: The ASCO CancerLinQ Discovery dataset was queried to identify patients diagnosed with lung cancer between the years 2010-2018. Data on demographics, tumor stage, histology and treatments were extracted, and receipt of molecular testing was investigated as the primary outcome. Univariate association of each clinicopathological variable with molecular testing outcome was performed using chi-square test for categorical variables and ANOVA test for numerical variables. A multivariable logistic regression analysis with …

IntroductionFirst-line therapy for patients with metastatic NSCLC includes checkpoint inhibitor monotherapy, dual checkpoint inhibition, or combination with chemotherapy. We compared outcomes with combination chemoimmunotherapy versus dual checkpoint inhibition as first-line treatment for patients with metastatic NSCLC.MethodsThis open-label, randomized clinical trial was conducted at 44 sites in Canada and Australia. Patients with treatment-naive, metastatic NSCLC without sensitizing EGFR or ALK alterations were randomized (1:1) to receive treatment with durvalumab plus tremelimumab with or without platinum-doublet chemotherapy. The primary end point was overall survival (OS). Secondary end points were progression-free survival, overall response rate, and safety.ResultsA total of 301 patients were randomized. Median OS was 16.6 months (95% confidence interval [CI]: 12.6–19.1) with …

Background Tumor hypoxia is attributed to aggressive biology of pancreatic ductal adenocarcinoma (PDAC). We previously reported that hypoxia correlated with rapid tumor growth and metastasis in patient derived xenografts. Anticipating a prognostic relevance of hypoxia in patient tumors, we developed protocols for semi-quantitative image analysis to provide objective, observer-independent measure of hypoxia. We further validated a method which is most efficient and accurate to assess tumor hypoxia, and can be applied broadly. Methods We studied the performance of three automated image analysis platforms in scoring pimonidazole-detectable hypoxia in resected PDAC (n=10). Multiple stained tumor sections were analyzed on 3 independent image-analysis platforms, Aperio Genie (AG), Definiens Tissue Studio (TS) and Definiens Developer (DD), which comprised of a customized rule-set. Results The output from, AG had good concordance with manual scoring, but the work-flow was resource-intensive and not suited for high throughput analysis (1). TS analysis had high levels of variability related to misclassification of cells class, while the customized rule-set of DD had a high level of reliability with an intra-class co-efficient of more than 85%. Discussion This work demonstrates the feasibility of developing a robust, high performance, pipeline for automated, quantitative scoring of pimonidazole-detectable hypoxia in patient tumors.

France: International Agency for Research on Cancer; 2008. 5. College of American Pathologists. Cancer protocols templates. https://www. cap. org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocol-templates. Accessed March 21, 2022. 6. Robert NJ, Nwokeji ED, Espirito JL, et al. Biomarker tissue journey among patients (pts) with untreated metastatic non-small cell lung cancer (mNSCLC) in the US Oncology

Purpose/Objective(s)The primary objective of this study was to identify factors associated with unexpected radiation therapy (RT) re-planning in Stage III non-small cell lung cancer (NSCLC). These factors may help predict which patients are more likely to require adaptive radical radiotherapy.Materials/MethodsStage III NSCLC patients treated in a single institution with radical intent RT from January 1, 2016, to December 31, 2019 were analyzed. Descriptive statistics were performed, including the frequency of RT re-planning and reason for re-planning. Logistic regression analysis was used to identify predictive factors associated with re-planning. Variables significant on univariate modelling, with a P value < 0.05, were selected for multivariate modelling.ResultsThere were 144 patients with Stage III NSCLC who met study criteria. Eighteen percent (n=26) of these patients required re-planning. The most common …

Background The current management of locally-advanced oesophageal adenocarcinoma (OAC) includes neoadjuvant therapy; however, there are no robust markers that predict treatment response. While 25% of patients will have a complete pathological response, up to 40% will have little or no response. Identification of this non-responsive subgroup prior to treatment and robust testing with alternative drug panels may help to generate personalised induction regimens. Patient derived organoids have shown some promise in other cancers as a model for personalised therapy. The aim of this study is to determine the feasibility of utilising PDOs to predict response to induction therapy. Methods PDOs were generated from endoscopic biopsies taken pre-treatment in patients with locally advanced (LA) or metastatic (M) esophageal cancer. For those with LA disease, samples were …

3039Background: Molecular profiling of tumor tissue is the gold standard for treatment decision making in advanced non-small cell lung cancer. Results may be delayed or unavailable due to insufficient tissue samples or prolonged wait times for biopsy, pathology assessment and testing. We piloted the use of plasma molecular testing as part of the initial diagnostic work-up for patients with suspected advanced lung cancer (NCT04863924). Methods: Patients with radiologic evidence of advanced lung cancer referred to the lung rapid diagnostic program underwent plasma circulating tumor DNA (ctDNA) testing using InVisionFirst-Lung, a next-generation sequencing (NGS) assay targeting 37 genes. Standard tissue testing was performed with comprehensive NGS (Oncomine). The primary endpoint was time to treatment in stage IV NSCLC patients compared to an historical pre-COVID-19 cohort (2018-9). Secondary …

IntroductionMutations in BRAF occur in 2% to 4% of patients with lung adenocarcinoma. Combination dabrafenib and trametinib, or single-agent vemurafenib is approved only for patients with cancers driven by the V600E BRAF mutation. Targeted therapy is not currently available for patients harboring non-V600 BRAF mutations.MethodsA lung adenocarcinoma patient-derived xenograft model (PHLC12) with wild-type and nonamplified EGFR was tested for response to EGFR tyrosine kinase inhibitors (TKIs). A cell line derived from this model (X12CL) was also used to evaluate drug sensitivity and to identify potential drivers by small interfering RNA knockdown. Kinase assays were used to test direct targeting of the candidate driver by the EGFR TKIs. Structural modeling including, molecular dynamics simulations, and binding assays were conducted to explore the mechanism of off-target inhibition by EGFR TKIs on …

IntroductionMolecular profiling of tumor tissue is the gold standard for treatment decision-making in advanced non-small cell lung cancer (NSCLC). Results may be delayed or unavailable due to insufficient tissue, prolonged wait times for biopsy, pathology assessment and testing. We piloted the use of plasma testing in the initial diagnostic workup for patients with suspected advanced lung cancer.MethodsPatients with ⩽15 pack-year smoking history and suspected advanced lung cancer referred to the lung cancer rapid diagnostic program underwent plasma circulating-tumor DNA testing using a DNA-based mutation panel. Tissue testing was performed per standard of care, including comprehensive next-generation sequencing (NGS). The primary endpoint was time from diagnostic program referral to cancer treatment in stage IV NSCLC patients (Cohort A) compared to a contemporary cohort not enrolled in the …

Proteome analysis revealed signatures of co-expressed upregulated metabolism proteins highly conserved between primary and non-small cell lung cancer (NSCLC) patient-derived xenograft tumors (Li et al. 2014, Nat. Communications 5:5469). The C10 signature is encoded by seven genes (ADSS, ATP2A2, CTPS1, IMPDH2, PKM2, PTGES3, SGPL1) and DNA alterations in C10-encoding genes are associated with longer survival in a subset of NSCLC. To explore the C10 signature as an oncogenic driver and address potential mechanisms of action, C10 protein expression and protein–protein interactions were determined. In independent NSCLC cohorts, the coordinated expression of C10 proteins was significant and mutations in C10 genes were associated with better outcome. Affinity purification-mass spectrometry and in vivo proximity-based biotin identification defined a C10 interactome involving 667 …

Purpose/Objective(s)In epidermal growth factor receptor mutated (EGFR+) metastatic non-small cell lung cancer (mNSCLC), pneumonitis is a known side effect independently associated with both Osimertinib and thoracic radiotherapy (TRT). The objective of this study was to examine the relationship between concurrent Osimertinib and TRT with regards to pneumonitis, and to observe patterns of practice regarding the cessation of Osimertinib during TRT.Materials/MethodsIn this single institution retrospective cohort study between 2016 and 2020, patients with EGFR+ mNSCLC who received both Osimertinib and TRT were included. TRT was defined as any course of radiotherapy that involved lung parenchyma within the treated field. The primary endpoint was the incidence of symptomatic (CTCAE grade ≥ 2) pneumonitis. Comparisons were made with multivariable Cox proportional hazards regression for both …

The extracellular matrix (ECM) is amongst many tissue components affected by cancer, however, morphological changes of the ECM are not well-understood and thus, often omitted from diagnostic considerations. Polarimetric second-harmonic generation (P-SHG) microscopy allows for visualization and characterization of collagen ultrastructure in the ECM, aiding in better understanding of the changes induced by cancer throughout the tissue. In this paper, a large region of hematoxylin and eosin (H&E) stained human lung section, encompassing a tumor margin, connecting a significant tumor portion to normal tissue was imaged with P-SHG microscopy. The resulting polarimetric parameters were utilized in principal components analysis and unsupervised K-Means clustering to separate normal- and tumor-like tissue. Consequently, a pseudo-color map of the clustered tissue regions is generated to highlight the …

IntroductionAccurate subtyping of NSCLC into lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) is the cornerstone of NSCLC diagnosis. Cytology samples reveal higher rates of classification failures, that is, subtyping as non–small cell carcinoma—not otherwise specified (NSCC-NOS), as compared with histology specimens. This study aims to identify specific algorithms on the basis of known cytomorphologic features that aid accurate and successful subtyping of NSCLC on cytology.MethodsA total of 13 expert cytopathologists participated anonymously in an online survey to subtype 119 NSCLC cytology cases (gold standard diagnoses being LUAD in 80 and LUSC in 39) enriched for nonkeratinizing LUSC. They selected from 23 predefined cytomorphologic features that they used in subtyping. Data were analyzed using machine learning algorithms on the basis of random forest method …

Extensive evidence exists to functionally implicate stromal cancer-associated fibroblasts in tumor progression. Data from experimental cancer models has questioned the exclusive tumor-supportive function of the tumor stroma and suggested that the stroma might also act as a barrier to inhibit tumor metastasis. With consideration of this shift in dogma, we discuss the role of a specific part of the tumor stroma, the insoluble extracellular matrix (ECM), in tumor growth and spread. We summarize data from experimental tumor models on the role of fibrillar collagens, the fibronectin EDA splice form, proteoglycans and the matricellular proteins, periostin and tenascins, which are all major components of the tumor stroma. In addition to the composition of the ECM being able to regulate tumorigenesis via integrin-mediated signaling, recent data indicate that the stiffness of the ECM also significantly impacts tumor growth and …

IntroductionIn addition to the higher prevalence of EGFR mutations found among lung cancer cases in East Asian patients, it is unclear whether there are differences in treatment outcomes by ethnicity—that is, East Asian versus non–East Asian.MethodsPatients diagnosed with EGFR-mutant lung cancer between January 2004 and October 2014 at a single center were reviewed. Data captured included demographics, tumor and treatment information, and survival. Survival of patients of East Asian and non–East Asian ancestry was compared, including in the subgroup that received EGFR tyrosine kinase inhibitor (TKI) for advanced disease and in those with early-stage disease that underwent surgical resection.ResultsA total of 348 patients with EGFR-mutant NSCLC were identified. There was a higher proportion of nonsmokers among those of East Asian ethnicity. No significant difference in survival was seen …

Purpose/Objective(s)Metastases directed therapy of oligometastatic colorectal cancer (CRC) may confer long-term disease advantages. However, there is a paucity of data to predict optimal patient selection. Our hypothesis is that pretreatment factors can identify patients at higher risk of early progression after SBRT for CRC oligometastases.Materials/MethodsAn institutional cohort was reviewed to identify patients with extracranial oligometastatic (≤ 5 metastases) colorectal cancer who received SBRT to all metastases. Outcomes of interest were local failure (LF), overall survival (OS) and progression-free survival (PFS). Recursive partitioning analysis (RPA) was performed to identify "early progression", defined as those having a PFS event within 6 months of SBRT, from a training set consisting of 70% of the cohort. The remaining 30% were used in the validation analysis of the model.ResultsFrom January 2008 to …

BackgroundTesting for tumor programmed death ligand-1 (PD-L1) expression was initially developed with histology specimens in non-small cell lung cancer (NSCLC). However, cytology specimens are widely used for primary diagnosis and biomarker studies in clinical practice. Limited clinical data exist on the predictiveness of cytology-derived PD-L1 scores for response to immune checkpoint inhibitor (ICI) therapy.MethodsWe reviewed all NSCLC specimens clinically tested at the University Health Network (UHN) for PD-L1 with 22C3 pharmDx, from 01/2013 to 04/2021. Treatment outcomes in patients treated with single agent ICI therapy were reviewed and compared according to cytology- and histology-derived PD-L1 scores.ResultsWe identified 494 and 1942 unique patients with cytology- and histology-derived tumor proportion scores, respectively, during the study period. Informative testing rates were 95 % vs …

There is currently an increased interest in understanding the role of the tumor microenvironment (TME) in tumor growth and progression. In this context the role of integrins in cancer-associated fibroblasts (CAFs) will need to be carefully re-evaluated. Fibroblast-derived cells are not only in the focus in tumors, but also in tissue fibrosis as well as in inflammatory conditions. The recent transcriptional profiling of what has been called “the pan-fibroblast cell lineage” in mouse and human tissues has identified novel transcriptional biomarker mRNAs encoding the secreted ECM proteins dermatopontin and collagen XV as well as the phosphatidylinositol-anchored membrane protein Pi16. Some of the genes identified in these fibroblasts scRNA-seq datasets will be useful for rigorous comparative characterizations of fibroblast-derived cell subpopulations. At the same time, it will be a challenge in the coming years to validate …

Diffuse malignant mesothelioma (MM) is an incurable tumour of the serosal membranes, which is often caused by exposure to asbestos and commonly diagnosed at advanced stage. Malignant mesothelioma in situ (MMIS) is now included as diagnostic category by the World Health Organization (WHO). However, our international survey of 34 pulmonary pathologists with an interest in MM diagnosis highlights inconsistency regarding how the diagnosis is being made by experts, despite published guidelines. Whilst the WHO restricts the diagnosis to surgical samples, the very concept has implication for cytological diagnosis, which is already regarded as controversial in itself by some. MMIS is currently only applicable as precursor to MM with an epithelioid component, and raises the possibility for different molecular pathways for different histological MM subtypes. The clinical implications of MMIS at this stage are …

e21127Background: KRAS alterations constitute the most common driver mutations in metastatic non-small cell lung cancers (mNSCLC) and occur in approximately 30% of patients. KRAS mutational subtype as well as the presence of co-mutations has been associated with altered activation of downstream signaling pathways in preclinical models. We hypothesize that different KRAS G12C mutational subsets will be associated with variable clinical outcome and response to therapy. To this end, we have performed a retrospective analysis of survival and treatment outcomes by KRAS mutation subtype (G12C vs non-G12C). Methods: A review of KRAS-mutated mNSCLC patients treated with immunotherapy between 2013 and 2020 was conducted. Patient demographics, smoking status, KRAS mutational subtype, co-mutations and PD-L1 status were collected. Overall response rate (ORR) and progression-free …

MethodsDTPs were generated through chronic exposure to osimertinib in a lung adenocarcinoma PDX models with EGFR exon-19 deletion and exon-19 deletion+ T790M mutation, respectively. Histological analysis, genomic clonal structure analysis using whole-exome sequencing (WES), transcriptomic analysis with single-cell RNA-seq were conducted on DTPs and compared to pre-treatment baseline (BL) tumors. To examine the reversibility of DTP feature and the detail clonal changes, DTPs were repopulated upon drug discontinuation and the regrowth tumors were compared to BL and DTPs.ResultsEGFR-mutant PDXs showed significant response to osimertinib. However, all PDX tumors regrew after drug release, indicating EGFR-TKI cannot eradicate EGFR-mutant lung cancer cells. The regrowth tumors consistently showed sensitivity to repeat treatment. Although DTPs exhibited distinct histologic features …

A minor population of cancer cells may evade cell death from chemotherapy and targeted therapy by entering a reversible slow proliferation state known as the drug tolerant persister (DTP) state. This DTP state can allow cancer cells to survive drug therapy long enough for additional mechanisms of acquired drug resistance to develop. Thus, cancer persistence is a major obstacle to curing cancers, where insight into the biology of DTP cells and therapeutic strategies targeting this mechanism can have considerable clinical implications. There is emerging evidence that DTP cells adapt to new environments through epigenomic modification, transcriptomic regulation, flexible energy metabolism, and interactions with the tumor microenvironment. Herein, we review and discuss the various proposed mechanisms of cancer persister cells and the molecular features underlying the DTP state, with insights into the potential …

Activating mutations in the epidermal growth factor receptor (EGFR) are common driver mutations in non-small cell lung cancer (NSCLC). First, second and third generation EGFR tyrosine kinase inhibitors (TKIs) are effective at inhibiting mutant EGFR NSCLC, however, acquired resistance is a major issue, leading to disease relapse. Here, we characterize a small molecule, EMI66, an analog of a small molecule which we previously identified to inhibit mutant EGFR signalling via a novel mechanism of action. We show that EMI66 attenuates receptor tyrosine kinase (RTK) expression and signalling and alters the electrophoretic mobility of Coatomer Protein Complex Beta 2 (COPB2) protein in mutant EGFR NSCLC cells. Moreover, we demonstrate that EMI66 can alter the subcellular localization of EGFR and COPB2 within the early secretory pathway. Furthermore, we find that COPB2 knockdown reduces the growth of …

Chronic viral infections increase severity of Mycobacterium tuberculosis (Mtb) coinfection. Here, we examined how chronic viral infections alter the pulmonary microenvironment to foster coinfection and worsen disease severity. We developed a coordinated system of chronic virus and Mtb infection that induced central clinical manifestations of coinfection, including increased Mtb burden, extra-pulmonary dissemination, and heightened mortality. These disease states were not due to chronic virus-induced immunosuppression or exhaustion; rather, increased amounts of the cytokine TNFα initially arrested pulmonary Mtb growth, impeding dendritic cell mediated antigen transportation to the lymph node and subverting immune-surveillance, allowing bacterial sanctuary. The cryptic Mtb replication delayed CD4 T cell priming, redirecting T helper (Th) 1 toward Th17 differentiation and increasing pulmonary neutrophilia …

BackgroundIn the current analysis, we characterize the prognostic significance of KRAS mutations with concomitant copy number aberrations (CNA) in early stage non-small cell lung cancer (NSCLC), and evaluate the ability to predict survival benefit from adjuvant chemotherapy.MethodsClinical and genomic data from the LACE (Lung Adjuvant Cisplatin Evaluation)-Bio consortium was utilized. CNAs were categorized as Gain (CN≥ 2) or Neutral (Neut)/Loss; KRAS status was defined as wild type (WT) or mutant (MUT). The following groups were compared in all patients and the adenocarcinoma subgroup, and were correlated to survival endpoints using a Cox proportional hazards model: WT+ Neut/Loss (reference), WT+ Gain, MUT+ Gain and MUT+ Neut/Loss. A treatment-by-variable interaction was added to evaluate predictive effect.ResultsOf the 946 (399 adenocarcinoma) NSCLC patients, 41 [30] had MUT …

BackgroundA successful lung cancer screening program requires a patient cohort at sufficient risk of developing cancer who are willing to participate. Among other factors, a patient’s lung cancer risk perception may inform their attitudes toward screening and smoking cessation programs.Research QuestionThis study analyzed data from the Pan-Canadian Early Detection of Lung Cancer (PanCan) Study to address the following questions: Which factors are associated with the perception of lung cancer risk? Is there an association between risk perception for lung cancer and actual calculated risk? Is there an association between risk perception for lung cancer and the intent to quit smoking? Are there potential targets for lung cancer screening awareness?Study Design and MethodsThe PanCan study recruited current or former smokers aged 50 to 75 years who had at least a 2% risk of developing lung cancer over 6 …

e21123Background: The treatment landscape for patients with metastatic non-small cell lung cancer (mNSCLC) with a MET exon 14 skipping mutation (MET ex14) is rapidly changing, with recent approvals of MET selective tyrosine kinase inhibitors (TKIs) and reports of durable response to immune checkpoint inhibitors (ICI), particularly among those with sarcomatoid histology. Currently there are no published data that inform the sequencing of TKIs and ICI regimens. We sought to characterize treatment patterns and outcomes in this population at 3 Ontario cancer centres. Methods: We reviewed all mNSCLC patients with MET ex14 identified by tissue or plasma NGS in the last 4 years. Patients with EGFR co-mutation or MET amplification alone were excluded. All systemic therapies and outcomes of overall response (ORR), progression free survival (PFS), overall survival (OS), and adverse events (AEs) were …

MethodsWe reviewed all NSCLC cytology and histology samples tested for PD-L1 using the 22C3 pharmDx assay at the University Health Network between 2013 and 2020. PD-L1 assessment on cytology samples was conducted with formalin-fixed paraffin-embedded cell blocks if a minimum of 100 “viable” tumor cells were present. Samples were received fresh or pre-fixed with CytoLyt. A subset of patients treated with ICIs at our center was reviewed for ORR and PFS and outcomes were compared between patients with PD-L1 assessment by cytology and histology.ResultsWe identified 487 and 1683 unique patients with cytology-and histology-derived PD-L1 expression, respectively. Informative testing rates were similar between cytology and histology (91.5% vs 93.0%; p= 0.27). The distribution of PD-L1 expression levels (≥ 50%/1-49%/< 1%) was 29.8%/27.9%/42.2% for cytology and 33.6%/26.9%/39.5% for …

BackgroundImmune checkpoint inhibitors (ICIs) have excellent systemic activity and are standard first line treatment in EGFR/ALK wild type metastatic non-small cell lung cancer (NSCLC). However, their role in patients with brain metastases, which affects over 20% of patients and cause significant morbidity, is less clear.MethodsWe reviewed patients with EGFR/ALK wild-type mNSCLC with CNS metastases. Serial MRIs were reviewed to determine the time to intracranial progression (iPFS). Multivariate regression was performed to adjust for the disease-specific graded prognostic score (ds-GPA).ResultsWe identified 36 ICI- and 33 chemotherapy-treated patients with baseline CNS metastases and available serial MRIs (average frequency:3.5 months). Baseline radiation was given except for 2 chemotherapy-treated patients with asymptomatic solitary metastasis. The CNS burden of disease was higher in the ICI …

Purpose/Objective(s)Pleurectomy/Decortication (P/D) has become a common lung-sparing surgical approach for MPM. Chemotherapy may be delivered in the neoadjuvant or adjuvant setting. Adjuvant hemithoracic IMPRINT was developed at Memorial Sloan Kettering Cancer Center and found safe in a multi-institutional phase II study, with promising survival outcomes. CTEP approved a phase III randomized cooperative group trial (NRG LU-006) to evaluate the efficacy of this lung-sparing trimodality treatment approach for resectable MPM.Materials/MethodsPatients with newly diagnosed MPM amenable to P/D are enrolled and undergo upfront P/D followed by adjuvant platinum/pemetrexed chemotherapy (preferred approach) or neoadjuvant chemotherapy followed by P/D. Patients are stratified by epithelioid vs. biphasic histologic subtype, achievement of a macroscopic complete resection (R0/1 vs. R2), and …

Quantifying response to drug treatment in mouse models of human cancer is important for treatment development and assignment, yet remains a challenging task. To be able to translate the results of the experiments more readily, a preferred measure to quantify this response should take into account more of the available experimental data, including both tumor size over time and the variation among replicates. We propose a theoretically grounded measure, KuLGaP, to compute the difference between the treatment and control arms. We test and compare KuLGaP to four widely used response measures using 329 patient-derived xenograft (PDX) models. Our results show that KuLGaP is more selective than currently existing measures, reduces the risk of false-positive calls, and improves translation of the laboratory results to clinical practice. We also show that outcomes of human treatment better align with the …

Simple Summary Understanding how the immune system navigate the tumor microenvironment is vital to developing effective drugs to treat cancer. Using gene and functional studies, we found that the collagen receptor LAIR2 is an important component of cancer regulation. When expressed in regulatory T cells, a LAIR2 containing gene signature is adversely prognostic in lung cancer. This study highlights the importance of microenvironment regulation of immune cells and provides a unique target for future therapeutic development. Abstract Cancer development requires a permissive microenvironment that is shaped by interactions between tumor cells, stroma, and the surrounding matrix. As collagen receptors, the leukocyte-associated immunoglobulin-like receptor (LAIR) family allows the immune system to interact with the extracellular matrix. However, little is known about their role in regulating tumor immunity and cancer progression. Methods: Genetic analysis of resected human lung adenocarcinoma was correlated to clinical-pathological characteristics, gene ontologies, and single cell RNA sequencing (scRNASeq). LAIR2 production was determined in subsets of immune cells isolated from blood leukocytes and lung adenocarcinoma tumor. Functional assays were used to determine the role of LAIR2 in tumorigenesis. Results: LAIR2 expression was adversely prognostic in lung adenocarcinoma. LAIR2 was preferentially produced by activated CD4+ T cells and enhanced in vitro tumor invasion into collagen. scRNASeq analysis of tumor infiltrating T cells revealed that LAIR2 expression co-localized with …

TPS2679Background: Immune checkpoint inhibitors (ICI) have demonstrated efficacy in a wide variety of cancers. Nevertheless, only a small proportion of patients derive a durable benefit. Mechanisms underlying primary and acquired resistance are still incompletely understood. They comprise tumor-intrinsic factors such as genomic and transcriptomic changes; upregulation of immunosuppressive subsets; T cell exhaustion; and promotion of an immune-tolerant tumor microenvironment. The collection of tumor biopsy at disease progression (PD) is challenging both in clinical and research settings as this often occurs at the time of treatment discontinuation. However, the analysis of these samples can lead to novel strategies to prevent or reverse immune resistance. Thus, the current approach to begin a profiling study with patients at the time of PD on ICI enables access and interrogation of such samples. Methods …

MethodsUsing a prospective cohort of patients with acquired TKI resistance, tumour tissue samples pre/post TKI exposure were identified. DNA was extracted from FFPE tissue using the Qiagen AllPrep DNA/RNA FFPE Extraction Protocol, and subsequently analyzed using the Illumina Infinium EPIC array. Raw microarray data files were processed using the software package minfi for data normalization (Illumina method) and extraction of methylation levels (M-values). Samples were split into two groups according to the T790M status of each sample (T790M+ or T790M-). The set of most informative probes, those whose M-value profiles align most closely with the T790M status of the study samples, was generated by selecting the 1,000 probes with lowest ANOVA’s p-value. The stability of the resulting sample clustering was assessed by hierarchical clustering (Euclidean distance), classification with internal cross …

Clinical trial results have recently demonstrated that inhibiting inflammation by targeting the interleukin‐1β pathway can offer a significant reduction in lung cancer incidence and mortality, highlighting a pressing and unmet need to understand the benefits of inflammation‐focused lung cancer therapies at the genetic level. While numerous genome‐wide association studies (GWAS) have explored the genetic etiology of lung cancer, there remains a large gap between the type of information that may be gleaned from an association study and the depth of understanding necessary to explain and drive translational findings. Thus, in this study we jointly model and integrate extensive multiomics data sources, utilizing a total of 40 genome‐wide functional annotations that augment previously published results from the International Lung Cancer Consortium (ILCCO) GWAS, to prioritize and characterize single nucleotide …

IntroductionThe efficacy of immune checkpoint inhibitors (ICIs) is low among EGFR-mutated non–small-cell lung cancer (NSCLC), although prolonged responses have occasionally been reported. We investigated the association between mutation subtypes and ICI outcomes among HER2- and EGFR-mutated NSCLC.Patients and MethodsThis retrospective single-center study analyzed patients with EGFR- and HER2-mutated advanced NSCLC who received at least 1 cycle of ICI between 2013 and 2019. Patient characteristics, mutation subtype, and ICI outcomes.ResultsAmong 48 patients with advanced NSCLC, 14 (29%) had HER2 mutations and 34 (71%) had EGFR mutations. EGFR mutations included 16 (47%) exon 19 deletion, 7 (21%) L858R, 5 (15%) uncommon, and 6 (18%) exon 20 insertion. Compared to EGFR-sensitizing mutations (ESMs), HER2 and EGFR exon 20 mutations were associated with a …

MethodsWe collected lung cancer cases diagnosed from 2010 to 2019, staged by 8 th edition TNM, from consenting institutions. We describe data sources, NSCLC characteristics and biomarker data (ALK, BRAF, EGFR, KRAS, ROS1, MET, RET, NTRK1, ERBB2 or PD-L1) submitted by Electronic Data Capture (EDC). We compared EDC cases with and without biomarker data as of April 1, 2021.ResultsOf 64,434 cases in the SPFC NSCLC database, 6611 (10%) were EDC cases (Figure), of which 2068 (31%) had biomarker data. Almost all cases were submitted from Asia, Australia, North America and Europe (Table). All biomarker data came from 14 countries, including China (28%), Canada (25%), Spain (15%), Australia (10%), and India (5%). Cases with biomarker data were more likely to be adenocarcinoma, advanced stage and non-surgical, although 46% had had surgery. Single gene tests predominated …

Thymic epithelial tumors are presently staged using a consistent TNM classification developed by the International Association for the Study of Lung Cancer (IASLC) and approved by the Union for International Cancer Control and the American Joint Committee on Cancer. The stage classification is incorporated in the eight edition of the TNM classification of thoracic malignancies. The IASLC Staging and Prognostic Factors Committee (SPFC)—Thymic Domain (TD) is in charge for the next (ninth) edition expected in 2024. The present article represents the midterm report of the SPFC-TD: in particular, it describes the unresolved issues identified by the group in the current stage classification which are worth being addressed and discussed for the ninth edition of the TNM classification on the basis of the available data collected in the central thymic database which will be managed and analyzed by Cancer Research …

Patients with non-small cell lung cancer (NSCLC) harboring ROS proto-oncogene 1 (ROS1) gene rearrangements show dramatic response to the tyrosine kinase inhibitor (TKI) crizotinib. Current best practice guidelines recommend that all advanced stage non-squamous NSCLC patients be also tested for ROS1 gene rearrangements. Several studies have suggested that ROS1 immunohistochemistry (IHC) using the D4D6 antibody may be used to screen for ROS1 fusion positive lung cancers, with assays showing high sensitivity but moderate to high specificity. A break apart fluorescence in situ hybridization (FISH) test is then used to confirm the presence of ROS1 gene rearrangement. The goal of Canadian ROS1 (CROS) study was to harmonize ROS1 laboratory developed testing (LDT) by using IHC and FISH assays to detect ROS1 rearranged lung cancers across Canadian pathology laboratories.Cell lines …

BackgroundAdjuvant platinum-based chemotherapy is standard of care for patients with resected stage IIA/B or IIIA NSCLC. Overall survival is suboptimal due to the high metastatic potential of early-stage NSCLC and there is substantial clinical need for additional efficacious adjuvant treatment options.MethodsPubMed (all time to 4 February 2021) and related conference databases were searched using the key search terms ‘NSCLC’ AND ‘Adjuvant’ AND ‘EGFR inhibitor’ OR respective aliases.ResultsThe literature search identified five adjuvant phase III trials of EGFR inhibitors in early NSCLC. The earlier BR19 and RADIANT trials failed to demonstrate statistically significant improvements in either OS or DFS for gefitinib and erlotinib, respectively, compared with placebo in patients with EGFR mutation-unselected NSCLC. Three subsequent phase III trials, ADAURA, CTONG1104, and IMPACT, were conducted in …

IntroductionThe addition of durvalumab after chemoradiation therapy (CRT) in unresectable stage III NSCLC significantly improves survival. The benefit of this approach in elderly patients is controversial given the toxicity associated with CRT and, thus, may be underutilized. We sought to investigate the outcomes of elderly patients treated with CRT without or without durvalumab at our center.MethodsWe reviewed all stage III patients with NSCLC treated with CRT between 2018 and 2020. Patients were analyzed on the basis of age: less than 70 years and 70 years and older. The end points evaluated were treatment patterns, toxicity, progression-free survival, and overall survival.ResultsThe baseline characteristics including Eastern Cooperative Oncology Group performance status and comorbidities were similar among the 115 patients (44 elderly, 71 young). Completion rates of CRT (100%, 97%) and …

Patient-derived xenograft (PDX) and their xenograft-derived organoid (XDO) models that recapitulate the genotypic and phenotypic landscape of patient cancers could help to advance research and lead to improved clinical management. PDX models were established from 276 pancreato-duodenal and biliary cancer resections. Initial, passage 0 (P0) engraftment rates were 59% (118/199) for pancreatic, 86% (25/29) for duodenal, and 35% (17/48) for biliary ductal tumors. Pancreatic ductal adenocarcinoma (PDAC), had a P0 engraftment rate of 62% (105/169). KRAS mutant and wild-type PDAC models were molecularly profiled, and XDO models were generated to perform initial drug response evaluations. Subsets of PDAC PDX models showed global copy number variants and gene expression profiles that were retained with serial passaging, and they showed a spectrum of somatic mutations represented in …

MethodsStage 3 NSCLC patients undergoing chemoradiation (CRT) and maintenance durvalumab were recruited prospectively to undergo serial blood collections at baseline and pre-and post-durvalumab. TCR repertoire analysis (capTCRseq) was performed on cfDNA using hybrid-capture TCR sequencing and TCR diversity/clonality was estimated using the Shannon’s and Simpson’s entropy index. Correlations between TCR clonality, response and PFS were examined using logistic and cox regressions.ResultsAmong 73 stage 3 NSCLC patients prospectively recruited to study, a pilot group of 22 patients who had completed induction CRT was analyzed for clonal TCR changes on treatment. In total, 17 received consolidation durvalumab, with best response of CR/PR in 7 (41%) SD in 8 (47%) and PD in 2 (12%). The median PFS from the start of durvalumab is 12.0 months (3.3-NR) and 53% of patients had …

Neurotrophic tyrosine receptor kinase gene fusions (NTRK) are oncogenic drivers present at a low frequency in most tumour types (<5%), and at a higher frequency (>80%) in a small number of rare tumours (e.g., infantile fibrosarcoma [IFS]) and considered mutually exclusive with other common oncogenic drivers. Health Canada recently approved two tyrosine receptor kinase (TRK) inhibitors, larotrectinib (for adults and children) and entrectinib (for adults), for the treatment of solid tumours harbouring NTRK gene fusions. In Phase I/II trials, these TRK inhibitors have demonstrated promising overall response rates and tolerability in patients with TRK fusion cancer who have exhausted other treatment options. In these studies, children appear to have similar responses and tolerability to adults. In this report, we provide a Canadian consensus on when and how to test for NTRK gene fusions and when to consider treatment with a TRK inhibitor for pediatric patients with solid tumours. We focus on three pediatric tumour types: non-rhabdomyosarcoma soft tissue sarcoma/unspecified spindle cell tumours including IFS, differentiated thyroid carcinoma, and glioma. We also propose a tumour-agnostic consensus based on the probability of the tumour harbouring an NTRK gene fusion. For children with locally advanced or metastatic TRK fusion cancer who have either failed upfront therapy or lack satisfactory treatment options, TRK inhibitor therapy should be considered.

On behalf of the Canadian Association of Medical Oncologists, we are pleased to present the Abstracts of the 2021 Annual Meeting. The National CAMO Residents Research Day was held virtually on 1 April 2021 and the CAMO Virtual Annual Scientific Meeting (ASM) & Annual General Meeting (AGM) took place on 22 April 2021. Twenty (20) abstracts were selected for presentation as oral presentations and rapid-fire presentations. Awards for the top three (3) abstracts were presented during the ASM and AGM. All of them were marked as “Award Recipient”. We congratulate all the presenters on their research work and contribution.

IntroductionProgrammed death-ligand 1 (PD-L1) is used as a biomarker for anti–programmed cell death protein-1 (PD-1) or anti-PD-L1 immunotherapies in NSCLC. We report here the results of population-based PD-L1 testing using the 22C3 IHC pharmDx Assay (Agilent Technologies) in a large Canadian regional reference pathology laboratory.MethodsTesting was conducted reflexively on biopsies and resections for NSCLC during an 8-month period. Tumor proportion score (TPS) cutoffs for low and high expression were 1% and 50%, respectively.ResultsAltogether, 2031 PD-L1 tests were performed on specimens from 1795 patients, with 107 inconclusive results (5.3%). Excluding cases with inconclusive/missing data, proportions for the remaining 1713 patients were 41.6% for TPS less than 1%, 28.6% for TPS 1% to 49%, and 29.8% for TPS greater than or equal to 50%. Higher PD-L1 expression rates were …

3126Background: Repeat molecular profiling, except to detect EGFR T790M, is not routinely performed in Canadian patients with lung cancer progressing on EGFR tyrosine kinase inhibitors (TKIs). We performed genomic profiling on post-progression biopsies in patients with stage IV non-small cell lung cancer (NSCLC) and known EGFR/ALK aberrations treated with TKIs to identify resistance mechanisms, evaluate options for subsequent treatment, and to assess clinical trial eligibility and costs. Methods: From Feb 2018-Aug 2020, post-progression tumour biopsies from consenting patients at a major cancer centre underwent genomic profiling (ThermoFisher OCA v3.0 including hotspots, fusions, and copy number variations in 161 cancer-associated genes). Outcomes of interest were the identification of resistance mutations, actionable targets, clinical trial eligibility (per clinicaltrials.gov), and costs. Results: Thirty …

Gain-of-function Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations occur in 25% of lung adenocarcinomas, and these tumors are challenging to treat. Some preclinical work, largely based on cell lines, suggested KRASmut lung cancers are especially dependent on the nuclear export protein exportin-1 (XPO1), while other work supports XPO1 being a broader cancer dependency. To investigate the sensitivity of KRASmut lung cancers to XPO1 inhibition in models that more closely match clinical tumors, we treated 10 independently established lung cancer patient-derived tumor xenografts (PDXs) with the clinical XPO1 inhibitor, Selinexor. Monotherapy with Selinexor reduced tumor growth in all KRASmut PDXs, which included 4 different codon mutations, and was more effective than the clinical MEK1/2 inhibitor, Trametinib. Selinexor was equally effective in KRASG12C and KRASG12D tumors, with …

Cancer cells bearing distinct KRAS mutations exhibit variable sensitivity to SHP2 inhibitors (SHP2i). Here we show that cells harboring KRAS Q61H are uniquely resistant to SHP2i, and investigate the underlying mechanisms using biophysics, molecular dynamics, and cell-based approaches. Q61H mutation impairs intrinsic and GAP-mediated GTP hydrolysis, and impedes activation by SOS1, but does not alter tyrosyl phosphorylation. Wild-type and Q61H-mutant KRAS are both phosphorylated by Src on Tyr32 and Tyr64 and dephosphorylated by SHP2, however, SHP2i does not reduce ERK phosphorylation in KRAS Q61H cells. Phosphorylation of wild-type and Gly12-mutant KRAS, which are associated with sensitivity to SHP2i, confers resistance to regulation by GAP and GEF activities and impairs binding to RAF, whereas the near-complete GAP/GEF-resistance of KRAS Q61H remains unaltered, and high …

Precision medicine in non-small cell lung cancer (NSCLC) is a rapidly evolving area, with the development of targeted therapies for advanced disease and concomitant molecular testing to inform clinical decision-making. In contrast, routine molecular testing in stage I–III disease has not been required, where standard of care comprises surgery with or without adjuvant or neoadjuvant chemotherapy, or concurrent chemoradiotherapy for unresectable stage III disease, without the integration of targeted therapy. However, the phase 3 ADAURA trial has recently shown that the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), osimertinib, reduces the risk of disease recurrence by 80 % versus placebo in the adjuvant setting for patients with stage IB–IIIA EGFR mutation-positive NSCLC following complete tumor resection with or without adjuvant chemotherapy, according to physician and patient …

Chronic viral infections increase severity of Mycobacterium tuberculosis (Mtb) coinfection, yet how they alter the pulmonary microenvironment to foster coinfection and worsen disease severity is unclear. We developed a coinfection model in mice with chronic lymphocytic choriomeningitis virus and Mtb coinfection that recapitulated the central clinical manifestations of coinfection, including increased Mtb burden, extra-pulmonary dissemination and heightened mortality. These long-term disease consequences were not due to chronic virus-induced immunosuppression or exhaustion, but instead were determined by early alterations in immune surveillance of Mtb coinfection. Mechanistically, increased chronic virus induced TNFα production initially arrested pulmonary Mtb growth, impeding dendritic cell mediated antigen transportation to the lung-draining lymph nodes (LNs) and allowing bacterial sanctuary. The …

Background: A minimally invasive cell-free DNA (cfDNA) blood test detecting multiple cancers at earlier stages could decrease cancer mortality. In earlier discovery work, whole-genome bisulfite sequencing outperformed whole-genome and targeted sequencing approaches for multi-cancer detection across stages at high specificity. Here, multi-cancer detection and tissue-of-origin (TOO) prediction using bisulfite sequencing of plasma cfDNA to identify methylomic signatures was evaluated in preparation for clinical validation, utility, and implementation studies. Methods: In all, 6,689 participants (2,482 cancer [> 50 cancers, all stages]; 4,207 non-cancer) were included in this prespecified substudy from the Circulating Cell-free Genome Atlas (CCGA) study (NCT02889978) and the STRIVE study (NCT03085888)-

MethodsmNSCLC patients treated with PD-1 inhibitors underwent baseline and serial blood collection. Patients who received combination therapy with CTLA-4 inhibitors or chemotherapy were excluded from this analysis. Peripheral blood mononuclear cells (PBMCs) were analyzed by high-dimensional flow cytometry using validated panels to evaluate T/B/NK-cell, Treg and myeloid populations. Plasma cytokines including TSLP were analyzed using ELISA and Luminex assays. Cox and logistic regressions were utilized to correlate biomarkers with progression-free survival (PFS), overall survival (OS) and radiographic response.Results30 mNSCLC patients treated with single-agent PD-1 inhibitors were included in the analysis. Higher pre-treatment TSLP levels were significantly associated with a 2-fold increase of monocytic (M)-MDSCs (CD33+/HLA-DR-/CD14+) in response to ICI treatment (p= 0.02). M-MDSC …

Immune-checkpoint inhibitors targeting PD-1 or PD-L1 have already substantially improved the outcomes of patients with many types of cancer, although only 20–40% of patients derive benefit from these new therapies. PD-L1, quantified using immunohistochemistry assays, is currently the most widely validated, used and accepted biomarker to guide the selection of patients to receive anti-PD-1 or anti-PD-L1 antibodies. However, many challenges remain in the clinical use of these assays, including the necessity of using different companion diagnostic assays for specific agents, high levels of inter-assay variability in terms of both performance and cut-off points, and a lack of prospective comparisons of how PD-L1+ disease diagnosed using each assay relates to clinical outcomes. In this Review, we describe the current role of PD-L1 immunohistochemistry assays used to inform the selection of patients to receive …

ROS1 rearrangements are identified in 1–2% of lung adenocarcinoma cases, and reflex testing is guideline-recommended. We developed a decision model for population-based ROS1 testing from a Canadian public healthcare perspective to determine the strategy that optimized detection of true-positive (TP) cases while minimizing costs and turnaround time (TAT). Eight diagnostic strategies were compared, including reflex single gene testing via immunohistochemistry (IHC) screening, fluorescence in-situ hybridization (FISH), next-generation sequencing (NGS), and biomarker-informed (EGFR/ALK/KRAS wildtype) testing initiated by pathologists and clinician-initiated strategies. Reflex IHC screening with FISH confirmation of positive cases yielded the best results for TAT, TP detection rate, and cost. IHC screening saved CAD 1,000,000 versus reflex FISH testing. NGS was the costliest reflex strategy. Biomarker-informed testing was cost-efficient but delayed TAT. Clinician-initiated testing was the least costly but resulted in long TAT and missed TP cases, highlighting the importance of reflex testing. Thus, reflex IHC screening for ROS1 with FISH confirmation provides a cost-efficient strategy with short TAT and maximizes the number of TP cases detected.

8547Background: Recently, it has been demonstrated that the addition of durvalumab after chemoradiation (CRT) in unresectable stage 3 non-small cell lung cancer (NSCLC) significantly improves overall survival (OS). The benefit of CRT in elderly patients is considered controversial given its increased toxicity. As such, CRT followed by durvalumab in elderly patients may be underutilized despite its demonstrated superiority. The practice pattern at our center is to offer curative treatment unless clearly contraindicated. We sought to investigate the outcomes of elderly patients treated with CRT +/- durvalumab at our center. Methods: We conducted a review of all stage 3 NSCLC patients treated with CRT between 2018 and 2020. Patients were analyzed based on age: < 70 years, ≥70 years. Endpoints evaluated were treatment patterns, toxicity, progression free survival (PFS) and overall survival (OS). Results: We …

Lung cancer is a highly heterogeneous disease often driven by well-characterized driver mutations. Although the best studied are common alterations in the epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) oncogenes, rapid advances in molecular characterization has led to the development of novel therapeutics that inhibit additional oncogenic alterations in advanced NSCLC. The literature search identified 62 eligible phase I/II clinical trials or integrated analyses of assessing novel targeted agents against the following molecular alterations: ROS1-rearranged, BRAF V600E-mutant, NTRK-rearranged, MET-altered, uncommon EGFR-mutant, RET-rearranged, HER2-positive, KRAS G12C-mutant and NRG1-rearranged. This rapidly evolving field has produced many new targeted treatment options and promising outcomes have led to the FDA approval of seven novel agents for use in …

This study identifies participants ineligible for lung cancer screening with the greatest likelihood of future eligibility. Lung cancer risk in participants enrolled in longitudinal lung screening was assessed using the Prostate, Lung, Colorectal and Ovarian lung cancer risk calculator (PLCOm2012) at two timepoints: baseline (T1) and follow-up (T2). Separate analyses were performed on four PLCOm2012 eligibility thresholds (3.25%, 2.00%, 1.50%, and 1.00%); only participants with a T1 risk less than the threshold were included in that analysis. Cox-models identified T1 risk factors associated with screen-eligibility at T2. Three models, applying differing assumptions of participant behavior, predicted future eligibility and were benchmarked against the observed cohort. Nine hundred and fifty-six participants had a T1 risk <3.25%; at 2.00% n= 755; at 1.50% n= 652; at 1.00% n= 484. Lung cancer risk increased over time in …

Objectives Numerous studies on malignant mesothelioma (MM) highlight the prognostic importance of histologic subtype, nuclear grade, and necrosis. This study compares these parameters in paired biopsy and resection specimens of pleural MM. Methods Histologic subtype, percentage of epithelioid morphology, nuclear grade, and the presence or absence of necrosis were compared in 429 paired biopsies and resection specimens of pleural MM from 19 institutions. Results Histologic subtype was concordant in 81% of cases (κ = 0.58). When compared with resection specimens, epithelioid morphology at biopsy had a positive predictive value (PPV) of 78.9% and a negative predictive value (NPV) of 93.5%; sarcomatoid morphology showed high PPV (92.9%) and NPV (99.3%), and biphasic morphology PPV was 89.7% and NPV was 79.7%. Agreement of …

BackgroundPD-L1 immunohistochemistry (IHC) is required to determine eligibility for pembrolizumab monotherapy in advanced non-small cell lung cancer (NSCLC) worldwide and for several other indications depending on the country. Four assays have been approved/CE-IVD marked, but PD-L1 IHC seems diversely implemented across regions and laboratories with the application of laboratory-developed tests (LDTs).MethodTo assess practice of PD-L1 IHC and identify issues and disparities, the IASLC pathology committee conducted a global survey for pathologists from January to May 2019, comprising multiple questions on pre-analytical, analytical and post-analytical conditions.

BackgroundA novel approach for managing malignant pleural mesothelioma, surgery for mesothelioma after radiotherapy (SMART), consisting of a short accelerated course of high-dose, hemithoracic, intensity modulated radiotherapy (IMRT) followed by extrapleural pneumonectomy was developed. The aim of this study was to evaluate the clinical feasibility of the SMART protocol.MethodsIn this single-centre, phase 2 trial, patients aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0–2, with histologically proven, resectable, cT1–3N0M0 disease who had previously untreated malignant pleural mesothelioma were eligible for inclusion. Patients received 25 Gy in five daily fractions over 1 week to the entire ipsilateral hemithorax with a concomitant 5 Gy boost to high risk areas followed by extrapleural pneumonectomy within 1 week. Adjuvant chemotherapy was offered to …

Cancer heterogeneity impacts therapeutic response, driving efforts to discover over-arching rules that supersede variability. Here, we define pan-cancer binary classes based on distinct expression of YAP and YAP-responsive adhesion regulators. Combining informatics with in vivo and in vitro gain- and loss-of-function studies across multiple murine and human tumor types, we show that opposite pro- or anti-cancer YAP activity functionally defines binary YAPon or YAPoff cancer classes that express or silence YAP, respectively. YAPoff solid cancers are neural/neuroendocrine and frequently RB1−/−, such as retinoblastoma, small cell lung cancer, and neuroendocrine prostate cancer. YAP silencing is intrinsic to the cell of origin, or acquired with lineage switching and drug resistance. The binary cancer groups exhibit distinct YAP-dependent adhesive behavior and pharmaceutical vulnerabilities, underscoring …

Background Chronic obstructive pulmonary disease (COPD) is an underdiagnosed condition sharing risk factors with lung cancer. Lung cancer screening may provide an opportunity to improve COPD diagnosis. Using Pan-Canadian Early Detection of Lung Cancer (PanCan) study data, the present study sought to determine the following: 1) What is the prevalence of COPD in a lung cancer screening population? 2) Can a model based on clinical and screening low-dose CT scan data predict the likelihood of COPD? Methods The single arm PanCan study recruited current or former smokers age 50–75 who had a calculated risk of lung cancer of at least 2% over 6 years. A baseline health questionnaire, spirometry, and low-dose CT scan were performed. CT scans were assessed by a radiologist for extent and distribution of emphysema. With spirometry …