基于RNA-based NGS检测非小细胞肺癌融合基因临床实践中国专家共识

基于RNA水平的二代测序(RNA-based next-generation sequencing, RNA-based NGS)技术已被非小细胞肺癌(non-small cell lung cancer, NSCLC)临床实践指南和专家共识推荐为融合基因的检测方法之一。NSCLC可用药靶点主要包括基因突变和融合,用于评估靶向治疗可行性的基因突变和融合基因检测均不可或缺。目前,基于DNA水平的NGS(DNA-based NGS)结合RNA-based NGS一次性同步检测基因突变和融合的技术已部分应用于临床实践。然而,RNA-based NGS检测融合基因的应用时机、应用场景和质控方面在我国仍缺乏规范和标准。本共识将进一步明确RNA-based NGS在融合基因检测中的应用时机、应用场景和质控,并给予指导性建议,推动RNA-based NGS在NSCLC临床诊疗中的应用,使患者能够最大程度地从融合基因检测中获益。

中国非小细胞肺癌免疫检查点抑制剂治疗专家共识(2019年版)

非小细胞肺癌(non-small cell lung cancer, NSCLC)是肺癌中最常见的病理类型,大多数NSCLC患者在确诊时已属晚期。对于驱动基因突变阴性的患者而言,目前的治疗仍以化疗为主,总体预后较差,改善治疗现状、获得长期生存是晚期NSCLC患者最迫切的需求。近年来,肿瘤免疫治疗发展迅速,免疫检查点抑制剂(immune checkpoint inhibitors, ICIs),尤其是以程序性死亡因子-1(programmed death-1, PD-1)/程序性死亡因子配体-1(programmed deathligand 1, PD-L1)为靶点的ICIs在驱动基因突变阴性的NSCLC治疗中取得了突破性的进展,为患者带来了生存获益,改变了NSCLC的治疗格局,显示出越来越重要的地位。由中国临床肿瘤学会(Chinese society of clinical oncology, CSCO)NSCLC专家委员会牵头,组织该领域的相关专家,在参考国内外文献、系统评价中外临床研究结果、结合专家经验与体会的基础上,达成统一意见并制定本共识,以期指导国内同行更好地应用ICIs治疗NSCLC。

中国非小细胞肺癌免疫检查点抑制剂治疗专家共识(2020年版)

非小细胞肺癌(non-small cell lung cancer,NSCLC)是肺癌最常见的病理类型。晚期NSCLC的系统性抗肿瘤治疗经历了化疗、靶向治疗及免疫治疗的变革,患者总体生存时间不断延长。免疫检查点抑制剂(immune checkpoint inhibitors,ICIs),尤其是程序性死亡分子-1(programmed cell death protein 1,PD-1)/程序性死亡分子配体-1(programmed death-ligand 1,PD-L1)抗体已成为表皮生长因子受体(epidermal growth factor receptor,EGFR)/间变性淋巴瘤激酶(anaplastic lymphoma kinase,ALK)阴性晚期NSCLC一线及二线的标准治疗和局部晚期NSCLC同步放化疗后标准治疗,并在辅助/新辅助治疗中显示出可喜的结果,改变了NSCLC整体治疗格局。随着越来越多的ICIs在国内获批肺癌适应证,中国临床肿瘤学会(Chinese Society of Clinical Oncology,CSCO)NSCLC专家委员会牵头,组织该领域的专家,结合2019年版专家共识,参考最新国内外文献、临床研究数据及系统评价,在专家共同讨论的基础上,达成统一意见并制定、更新本共识,为国内同行更好地应用ICIs治疗NSCLC提供参考意见。

肿瘤突变负荷应用于肺癌免疫治疗的专家共识

肺癌是全球范围内发病率和死亡率最高的恶性肿瘤之一。免疫检查点抑制剂(immune checkpoint inhibitors,ICIs),包括程序性死亡受体1(programmed cell death 1,PD-1)抗体、程序性死亡受体1配体(programmed cell death ligand 1,PD-L1)抗体和细胞毒性T淋巴细胞相关蛋白4(cytotoxic T lymphocyte antigen 4,CTLA-4)抗体,给部分晚期肺癌患者带来了显著的生存获益,改变了晚期肺癌的治疗格局。既往研究表明,PD-1/PD-L1抗体在晚期非小细胞肺癌(non-small cell lung cancer,NSCLC)中的客观缓解率只有20%左右。所以临床亟需可靠的生物标志物协助筛选ICIs潜在获益人群,提高治疗响应率。肿瘤突变负荷(tumor mutational burden,TMB)是除PD-L1表达以外新兴的免疫治疗标志物。肺癌中PD-L1表达与TMB的相关性不大,评估TMB可扩大免疫治疗的获益人群。然而在临床实践中,TMB的检测、阈值的确定和临床指导策略仍然没有形成规范。本共识将对TMB检测和应用场景给出指导性建议,以促进TMB在肺癌免疫治疗中应用的规范化。

Prognostic factors of refractory NSCLC patients receiving anlotinib hydrochloride as the third-or further-line treatment

Objective:Anlotinib hydrochloride is a multitarget tyrosine kinase inhibitor that targets vascular endothelial growth factor receptor,fibroblast growth factor receptor,platelet-derived growth factor receptor,c-Kit,and c-MET;therefore,it exhibits both antitumor and anti-angiogenetic activities.A phase III trial has shown that anlotinib improved progression-free survival(PFS)and overall survival(OS)in patients with advanced non-small cell lung cancer(NSCLC),who presented with progressive disease or intolerance after standard chemotherapy.This study aimed to analyze the characteristics of patients receiving anlotinib treatment to determine the dominant populations who are fit for the treatment.Methods:Data were collected from March 2015 to January 2017 from a randomized,double-blind,placebo-controlled,multicenter,phase III trial of anlotinib(ALTER0303).A total of 437 patients were enrolled and randomly allocated(2:1)to the anlotinib and placebo groups.Kaplan–Meier analysis and log-rank test were performed to compare PFS and OS.Cox proportional hazards model was adopted for multivariate prognostic analysis.Results:Multivariate analysis indicated that high post-therapeutic peripheral blood granulocyte/lymphocyte ratio and elevated alkaline phosphatase levels were independent risk factors for PFS.Meanwhile,elevated thyroid-stimulating hormone,blood glucose,and triglyceride levels;hypertension;and hand–foot syndrome were independent protective factors of PFS.High posttherapeutic peripheral blood granulocyte/lymphocyte ratio,an Eastern Cooperative Oncology Group(ECOG)score≥2,and the sum of the maximal target lesion length at baseline were independent risk factors of OS,and hypertriglyceridemia was an independent protective factor of OS.Conclusions:This study preliminarily explored the possible factors that affected PFS and OS after anlotinib treatment in patients with advanced refractory NSCLC,and the baseline characteristics of the therapeutically dominant populations were then identified.

Efficacy and safety evaluation of icotinib in patients with advanced non-small cell lung cancer

Objective: To evaluate the efficacy and safety of icotinib hydrochloride in patients with advanced non-small cell lung cancer (NSCLC). Methods: A total of 89 patients with stage ⅢB or IV NSCLC received icotinib at a dose of 125 mg administered 3 times a day. Icotinib treatment was continued until disease progression or development of unacceptable toxicity. Results: A total of 89 patients were assessable. In patients treated with icotinib, the overall response rate (RR) was 36.0% (32/89), and the disease control rate (DCR) was 69.7% (62/89). RR and DCR were significantly improved in patients with adenocarcinoma versus non-adenocarcinoma (P<0.05). The symptom improvement rate was 57.3% (51/89), and the main symptoms improved were cough, pain, chest distress, dyspnea, and Eastern Cooperative Oncology Group performance status. The main toxic effects were rash [30/89 (33.7%)] and diarrhea [15/89 (16.9%)]. The level of toxicity was typically low. Conclusions: The use of icotinib hydrochloride in the treatment of advanced NSCLC is efficacious and safe, and its toxic effects are tolerable.

Equivalent efficacy study of QL1101 and bevacizumab on untreated advanced non-squamous non-small cell lung cancer patients: a phase 3 randomized, double-blind clinical trial

Objective:This phase 3 study aimed to test equivalence in efficacy and safety for QL1101,a bevacizumab analogue in Chinese patients with untreated locally advanced non-squamous non-small cell lung cancer(NSCLC).Methods:Eligible patients were randomly assigned 1:1 to receive carboplatin and paclitaxel in combination with either QL1101 or bevacizumab,15 mg/kg every 3-week for 6 cycles.This was followed by maintenance treatment with single agent QL1101 every 3-week.The primary end-point was objective response rate(ORR),with secondary end-points being progression-free survival(PFS),overall survival(OS),disease control rate(DCR),and adverse events(AEs).Results:Of 675 patients,535 eligible patients were randomized to the QL1101 group(n=269)and bevacizumab group(n=266).ORRs were 52.8%and 56.8%,respectively,for the QL1101 and bevacizumab groups,with an ORR hazard ratio 0.93(95%confidence interval:0.8-0131.1).The PFS,OS,DCR,and AEs were comparable between the 2 groups,which remained the same after stratification according to epidermal growth factor receptor mutation or smoking history.Conclusions:QL1101 showed similar efficacy and safety profiles as compared to bevacizumab among Chinese patients with untreated locally advanced non-squamous NSCLC.

帕博利珠单抗单药或联合化疗对PD-L1≥50%晚期NSCLC疗效的回顾性分析

目的该研究旨在评估及比较帕博利珠单抗联合含铂化疗(pembrolizumab plus platinum-based chemotherapy,PC)或帕博利珠单抗单药治疗(pembrolizumab monotherapy, PM)对程序性死亡配体1(programmed death ligand 1, PD-L1)肿瘤比例评分(tumor proportion score, TPS)≥50%的晚期非小细胞肺癌(non-small cell lung cancer, NSCLC)患者的疗效。方法回顾性分析比较PM和PC作为一线治疗时,对PD-L1-TPS≥50%且无表皮生长因子受体(epidermal growth factor receptor,EGFR)和间变性淋巴瘤激酶(anaplastic lymphoma kinase, ALK)突变NSCLC患者的疗效。结果研究纳入115例PC和91例PM治疗患者。至2020年12月30日,中位随访时间为17.13个月。PC和PM组中位无进展生存期(progression-free survival, PFS)分别为12.37个月和9.60个月(HR:0.44, P<0.001)。中位总生存期(overall survival, OS)分别为未能评估(not evaluable, NE)和28.91个月(HR:0.40, P=0.005)。亚组分析发现,除脑转移患者外,PC对大多数患者的PFS均有显著改善。PC和PM组的1年OS率分别为89.3%和76.1%;客观缓解率分别为61.7和46.9%(P=0.004)。结论标准含铂化疗基础上联合帕博利珠单抗似乎是初治、PD-L1≥50%、无EGFR或ALK突变的晚期NSCLC患者治疗的更优方案,需前瞻性研究验证该结论。

Equivalent efficacy assessment of QL1101 and bevacizumab in nonsquamous non-small cell lung cancer patients:A two-year follow-up data update

Objective: Anti-vascular endothelial growth factor(VEGF) monoclonal antibodies are an effective means of treating non-small cell lung cancer(NSCLC). Here, we aim to update the equivalent efficacy assessment between QL1101 and bevacizumab based on two-year follow-up data.Methods: In total, 535 eligible NSCLC patients were enrolled in this randomized controlled trial. Patients were randomly assigned 1:1 to the QL1101 group and the bevacizumab group. The full end time of this study was defined as 24 months after the last enrolled patient was randomized. The primary endpoint was the objective response rate(ORR);equivalence was confirmed if the two-sided 90% confidence interval(90% CI) of the relative risk was within the range of 0.75-1.33. The secondary endpoints were progression-free survival(PFS) and overall survival(OS).Results: The two-year updated data showed similar ORR(QL1101 vs. bevacizumab: 53.1% vs. 54.3%;relative risk=0.977;90% CI: 0.838-1.144), PFS(235 d vs. 254 d, log-rank P=0.311), and OS(577 d vs. 641 d, log-rank P=0.099) results between the QL1101 group and the bevacizumab group. The mean shrinkage ratio of targeted lesions was also similar between the QL1101 group and the bevacizumab group(22.5% vs. 23.5%). For patients who received QL1101 maintenance therapy, similar results were shown between the QL1101 group(n=157) and the bevacizumab group(n=148)(PFS: 253 d vs. 272 d, log-rank P=0.387;OS: 673 d vs. 790 d, log-rank P=0.101;mean tumor shrinkage rate: 26.6% vs. 27.5%).Conclusions: This study reported that QL1101 had similar efficacy in treating nonsquamous NSCLC in terms of ORR, PFS and OS based on two-year updated data, providing a basis for the clinical application of QL1101.

Advances in Lung Cancer and Treatment Research

With the advances in surgery, chemotherapy, and radiotherapy over the last decades, the treatment strategies of lung cancer has been largely changed. In this review, we summarize recent advances in lung cancer and treatment research. We discuss current clinical management, highlight stage-specific therapy approaches, chemotherapy options for advanced-stage of non-small-cell lung cancer (NSCLC) patients, along with new agents such as epidermal growth factor receptor (EGFR)-targeting tyrosine kinase inhibitors erlotinib and gefitinib, and the anaplastic lymphoma kinase (ALK) inhibitor crizotinib. We also give an outlook into NSCLC disease biology, focuse on the importance of EGFR activating mutations and the role of the tumor-microenvironment. Finally we summarize the new recommendations in treating small-cell-lung cancer (SCLC).

P53、C-erbB-2和VEGF在非小细胞肺癌中的表达及其临床意义(英文)

Objective: To investigate the expressions and the clinical significance of P53, C-erbB-2 and vascular endothelial growth factor (VEGF) in non-small cell lung cancer (NSCLC). Methods: 121 specimens of NSCLC were examined for P53, C-erbB-2 and VEGF by immunohistochemical staining. Results: The positive rates of P53, C-erbB-2 and VEGF in the carci- nomatous tissue were 43%, 39% and 31% respectively. P53 gene protein expression in lung cancer was significantly related to histological type and P-TNM staging of lung cancer patients (P < 0.05), and was not associated with the sex, age, the size of primary cancer, lymph node metastasis and cell differentiation (P > 0.05). C-erbB-2 gene protein expression in lung cancer was closely related to histological type and cell differentiation (P < 0.05), and was not associated with the sex, age, the size of primary cancer, lymph node metastasis and P-TNM staging of lung cancer patients (P > 0.05). VEGF in lung cancer was only closely related to cell differentiation (P < 0.05), and was not associated with the sex, age, the size of primary cancer, lymph node metastasis, histological type and P-TNM staging of lung cancer patients (P > 0.05). Conclusion: It is possible for P53, C-erbB-2 and VEGF to play an important role in the oncogenesis and development of non-small cell lung cancer.

Identification of FUT7 hypomethylation as the blood biomarker in the prediction of early-stage lung cancer

Early detection of lung cancer (LC) is vital for reducing LC-related mortality. However, noninvasive diagnostic tools remain a great challenge. We aim to identify blood-based biomarkers for the early detection of LC. Here, LC-associated hypomethylation in alpha-1,3-fucosyltransferase VII (FUT7) is identified via the Illumina 850K array in a discovery study and validated by mass spectrometry in two independent casecontrol studies with blood samples from 1720 LC patients (86.8% LC at stage I, blood is collected before surgery and treatment) and 3143 healthy controls. Compared to the controls, blood-based FUT7 hypomethylation is identified in LC patients at stage I, and even in LC patients with malignant nodules ≤1 cm and in patients with adenocarcinoma in situ. Gender plays a role in the LC-associated FUT7 hypomethylation in blood, which is more significant in males than in females. We also reveal that FUT7 hypomethylation in LC could be enhanced by the advanced stage of cancer, involvement of lymph nodes, and larger tumor size. Based on a large sample size and semi-quantitative methods, our study reveals a strong association between blood-based FUT7 hypomethylation and LC, suggesting that methylation signatures in blood may be a group of potential biomarkers for detection of early-stage LC.

Third-line or above anlotinib in relapsed and refractory small cell lung cancer patients with brain metastases:A post hoc analysis of ALTER1202,a randomized,double-blind phase 2 study

Background:The prognosis of patients with small cell lung cancer(SCLC)and brain metastases(BM)was poor.This study aimed to explore the efficacy and safety of anlotinib as third-line or above treatment in SCLC with BM.Methods:This was a subgroup analysis of the ALTER1202 trial,which was a randomized,placebo-controlled trial aimed to evaluate the role of anlotinib as third-line treatment or above in patients with SCLC.This study included patients with BM at baseline.The efficacy and safety outcomes included progression-free survival(PFS),overall survival(OS),central nervous system(CNS),objective response rate(ORR),CNS disease control rate(DCR),time to CNS progression,and adverse events(AEs).Results:Twenty-one and nine patients with BM were included in the anlotinib and placebo groups,respectively.The median PFS and OS were 3.8 months(95%confidence interval[CI]:1.8-6.1)and 6.1 months(95%CI:4.1-8.0)in the anlotinib group.Anlotinib was associated with a significant improvement in PFS(hazard ratio[HR]=0.15,95%CI:0.04-0.51,p=0.0005)and OS(HR=0.26,95%CI:0.09-0.73,p=0.0061)than placebo.Anlotinib significantly prolonged the time to CNS progression(p<0.0001).The anlotinib group had a higher CNS DCR than placebo(95.2%vs.22.2%,p=0.0001).The most common grade 3 or higher AEs were increased lipase(19.0%),hypertension(14.3%),and hyponatremia(14.3%)in the anlotinib group.Conclusions:Anlotinib proved to have potential CNS activity and a manageable toxicity profile in patients with SCLC and BM,significantly delaying CNS progression.

Allogeneic Vγ9Vδ2 T-cell immunotherapy exhibits promising clinical safety and prolongs the survival of patients with late-stage lung or liver cancer

Vγ9Vδ2 T cells are promising candidates for cellular tumor immunotherapy.Due to their HLA-independent mode of action,allogeneic Vγ9Vδ2 T cells can be considered for clinical application.To apply allogeneic Vγ9Vδ2 T cells in adoptive immunotherapy,the methodology used to obtain adequate cell numbers with optimal effector function in vitro needs to be optimized,and clinical safety and efficacy also need to be proven.Therefore,we developed a novel formula to improve the expansion of peripheralγδT cells from healthy donors.Then,we used a humanized mouse model to validate the therapeutic efficacy of expandedγδT cells in vivo;furthermore,the expandedγδT cells were adoptively transferred into late-stage liver and lung cancer patients.We found that the expanded cells possessed significantly improved immune effector functions,including proliferation,differentiation,and cancer cell killing,both in vitro and in the humanized mouse model.Furthermore,a phase I clinical trial in 132 late-stage cancer patients with a total of 414 cell infusions unequivocally validated the clinical safety of allogeneic Vγ9Vδ2 T cells.Among these 132 patients,8 liver cancer patients and 10 lung cancer patients who received≥5 cell infusions showed greatly prolonged survival,which preliminarily verified the efficacy of allogeneic Vγ9Vδ2 T-cell therapy.Our clinical studies underscore the safety and efficacy of allogeneic Vγ9Vδ2 T-cell immunotherapy,which will inspire further clinical investigations and eventually benefit cancer patients.

Anlotinib as third- or further-line therapy for short-term relapsed small-cell lung cancer: subgroup analysis of a randomized phase 2 study (ALTER1202)

Patients with small-cell lung cancer (SCLC) relapse within months after completing previous therapies. This study aimed to investigate the efficacy and safety of anlotinib as third- or further-line therapy in patients with short-term relapsed SCLC from ALTER1202. Patients with short-term relapsed SCLC (disease progression within 3 months after completing ≥ two lines of chemotherapy) in the anlotinib (n = 67) and placebo (n = 34) groups were analyzed. The primary endpoint was progression-free survival (PFS). The secondary endpoints included overall survival, objective response rate (ORR), disease control rate, and safety. Anlotinib significantly improved median PFS/OS (4.0 vs. 0.7 months, P < 0.0001)/(7.3 vs. 4.4 months, P = 0.006) compared with placebo. The ORR was 4.5%/2.9% in the anlotinib/placebo group (P = 1.000). The DCR in the anlotinib group was higher than that in the placebo group (73.1% vs. 11.8%, P < 0.001). The most common adverse events (AEs) were hypertension (38.8%), loss of appetite (28.4%), and fatigue (22.4%) in the anlotinib group and gamma-glutamyl transpeptidase elevation (20.6%) in the placebo group. No grade 5 AEs occurred. For patients with short-term relapsed SCLC, third- or further-line anlotinib treatment was associated with improved survival benefit. Further studies are warranted in this regard.

Genetic insights into thymic carcinomas and thymic neuroendocrine neoplasms denote prognosis signatures and pathways

Background:Thymic carcinomas(TCs)and thymic neuroendocrine neoplasms(TNENs)are two aggressive subtypes of thymic malignancy.Traditional therapy for advanced TCs and TNENs has limited outcome.New genomic profiling of TCs and TNENs might provide insights that contribute to the development of new treatment approaches.Methods:We used gene panel sequencing technologies to investigate the genetic aberrations of 32 TC patients and 15 TNEN patients who underwent surgery at Shanghai Chest Hospital between 2015 and 2017.Patient samples were sequenced using a 324-gene platform with licensed technologies.In this study,we focused on clinically relevant genomic alterations(CRGAs),which are previously proven to be pathogenic alterations,to identify the pathology-specific mutational patterns,prognostic signatures of TCs and TNENs.Results:The mutational profiles between TCs and TNENs were diverse.The genetic alterations that ranked highest in TCs were in CDKN2A,TP53,ASXL1,CDKN2B,PIK3C2G,PTCH1,and ROS1,while those in TNENs were in MEN1,MLL2,APC,RB1,and TSC2.Prognostic analysis showed that mutations of ROS1,CDKN2A,CDKN2B,BRAF,and BAP1 were significantly associated with worse outcomes in TC patients,and that mutation of ERBB2 indicated shortened disease-free survival(DFS)and overall survival(OS)in TNEN patients.Further investigation found that the prognosis-related genes were focused on signal pathways of cell cycle control,chromatin remodeling/DNA methylation,phosphoinositide 3-kinases(PI3K)/protein kinase B(AKT)/mammalian target of rapamycin(mTOR),and receptor tyrosine kinase(RTK)/RAS/mitogen-activated protein kinase(MAPK)signaling.Conclusion:We profiled the mutational features of 47 Chinese patients with thymic malignancy of diverse pathologic phenotypes to uncover the integrated genomic landscape of these rare tumors,and identified the pathology-specific mutational patterns,prognostic signatures,and potential therapeutic targets for TCs and TNENs.