Therapeutic strategies for EGFR-mutated non-small cell lung cancer patients with osimertinib resistance

A clinical review on third and fourth generation EGFR tyrosine kinase inhibitors for the treatment of non-small cell lung cancer

"Epidermal growth factor receptor (EGFR)" mutations are pivotal in the pathogenesis of "Non-Small Cell Lung Cancer (NSCLC)," which is associated with high morbidity and mortality rates. The advent of third and fourth-generation EGFR tyrosine kinase inhibitors (TKIs) has significantly advanced the therapeutic landscape for EGFR-mutant NSCLC, particularly in overcoming resistance mutations such as T790M and C797S. This review delves into the current clinical status, efficacy, safety profiles, and regulatory approvals of third-generation EGFR TKIs, including Osimertinib, Lazertinib, Furmonertinib, Aumolertinib, Rezivertinib, Befotertinib, Sunvozertinib. Furthermore, it explores emerging fourth-generation EGFR TKIs designed to address resistance mechanisms beyond those targeted by their predecessors. Notable fourth-generation candidates such as TQB3804, BPI-361175, BDTX-1535, WJ13404, QLH11811, H002, HS-10375, BBT-207, JIN-A02, and HS-10504 are highlighted for their potential to overcome the C797S mutation. The review emphasizes the importance of these advanced inhibitors in enhancing "progression-free survival and overall survival rates". By evaluating the therapeutic potential and limitations of these EGFR TKIs, this review aims to guide future research in the management of EGFR-mutant NSCLC. This acts as guiding beacon for the strategic design and development of third and fourth generation EGFR-TK inhibitors to overcome the drug resistance hurdles in the development of EGFR-TK inhibitors.

Liensinine overcomes EGFR-TKI resistance in lung adenocarcinoma through DRP1-mediated autophagy

INTRODUCTION

Persistent upregulation of autophagy contributes to tumour cells' resistance to EGFR-TKI therapy, and hence, inhibiting autophagy could be a valuable strategy for overcoming such resistance.

OBJECTIVES

This study investigated the effects of liensinine in EGFR-TKI resistant lung adenocarcinoma (LUAD) and to explore the underlying mechanism.

METHODS

CCK-8 assay, colony formation, EdU assay and apoptosis assays were conducted for investigating the effect of EGFR-TKI and liensinine combination treatment in LUAD. Furthermore, autophagic flux were detected by western blot, fluorescence assays and TEM. In addition, by employing a DARTS approach, a CETSA assay, and SPR analysis, we identified DRP1 as a target of liensinine. Finally, by establishing a xenograft model of the disease, the impact of combination treatment in vivo was assessed.

RESULT

In vitro and in vivo experiments revealed that the novel autophagy inhibitor liensinine enhanced the sensitivity of LUAD to EGFR-TKIs. This effect was achieved by inhibiting autophagic flux. We then examined whether liensinine inhibits autophagic flux through the impairment of autophagosome and autolysosome degradation. Furthermore, we identified DRP1 as a target of liensinine. The activation of DRP1 by liensinine through dephosphorylation at Ser637 promotes the accumulation of autophagosomes and autolysosomes while simultaneously blocking autophagic flux, thereby enhancing the cancer cell-killing effects of EGFR-TKIs.

CONCLUSIONS

Our study validated the efficacy of liensinine in overcoming EGFR-TKI resistance and elucidated the mechanism underlying liensinine's inhibition of autophagy.

Protein Nanoparticles Simultaneously Displaying TRAIL and EGFR-Binding Ligands Effectively Induce Apoptotic Cancer Cell Death and Overcome EGFR-TKI Resistance in Lung Cancer

Lung cancer remains one of the most lethal cancers globally, with nonsmall cell lung cancer (NSCLC) representing the predominant subtype. Despite significant advancements in targeted therapies, overcoming therapeutic resistance in NSCLC remains a significant challenge, particularly in cases resistant to tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs). Here, we developed target-specific, apoptosis-inducing protein nanoparticles using Aquifex aeolicus lumazine synthase (AaLS), which were engineered to simultaneously display multiple TRAIL molecules and EGFR-binding ligands, including EGFR affibody (Afb) or anti-EGFR nanobodies (7D12, 9G8, and EgB4). These nanoparticles utilize the EGFR-binding ligand to enhance selective targeting of EGFR-overexpressing lung adenocarcinoma (PC9, HCC827, A549) and squamous cell carcinoma (H226) cells, regardless of mutations within the intracellular kinase domain of EGFR, which are primarily driven by tyrosine kinase inhibitors commonly used as first-line treatments in lung cancer therapy. The codisplayed EGFR-binding ligands enhance the attachment of TRAIL-displaying protein nanoparticles to cancer cells by stabilizing interactions with EGFR, promoting cell surface clustering of TRAIL molecules and improving TRAIL engagement with death receptors (DRs). This sustained interaction significantly amplifies TRAIL-mediated apoptotic cancer cell death signaling, effectively overcoming both TRAIL and EGFR-TKI resistance in NSCLC cells. Our findings suggest that dual ligand-displaying protein nanoparticles targeting DRs and EGFR represent a promising therapeutic strategy to potentiate TRAIL efficacy and circumvent EGFR-TKI resistance in NSCLC.

AHSA1-HSP90AA1 complex stabilized IFI6 and TGFB1 promotes mitochondrial stability and EMT in EGFR-mutated lung adenocarcinoma under Osimertinib pressure

Tyrosine kinase inhibitors (TKIs) have substantially improved the management of lung adenocarcinoma harboring epidermal growth factor receptor (EGFR) mutations, however, not all patients can derive benefit from it. We found that the overexpression of IFI6 under the influence of the AHSA1-HSP90AA1 complex significantly enhances Osimertinib resistance in EGFR-mutated lung adenocarcinoma cells. This effect is achieved by stabilizing mitochondrial function, reducing apoptosis, and promoting cell survival pathways via increased Akt phosphorylation. Additionally, we revealed that TGFB1 further promotes epithelial-mesenchymal transition (EMT) and enhances the invasive and migratory capabilities of these cells, thereby intensifying resistance. Regarding mechanisms, the AHSA1-HSP90AA1 complex stabilizes IFI6 and TGFB1 to enhance cell survival and Osimertinib resistance in EGFR mutant lung adenocarcinoma. IFI6 not only aids in cellular survival under drug stress but also promotes aggressive tumor phenotypes, suggesting its viability as a novel biomarker and therapeutic target for overcoming primary TKI resistance.

Targeted Degradation of EGFR Mutations via Self-Delivery Nano-PROTACs for Boosting Tumor Synergistic Immunotherapy

Proteolysis targeting chimera (PROTAC) has recently emerged as a promising strategy to selectively degrade target proteins in the treatment of various diseases. However, it has low bioavailability due to strong hydrophobicity, poor membrane permeability, and nonspecific distribution in vivo, which greatly limits its application. In this study, self-delivery PROTAC nanoparticles (designated as CP NPs) integrating gefitinib-based PROTACs and photosensitizers were developed to efficiently degrade mutated epidermal growth factor receptor (EGFR), a crucial kinase for cell growth and survival, while simultaneously triggering photodynamic therapy and immunotherapy. The prepared NPs enhanced the tumor accumulation of PROTACs, which led to the selective degradation of EGFR mutations and a reduction in programmed cell death protein ligand 1 levels, thereby alleviating tumor immunosuppression and immune tolerance. Moreover, under laser irradiation, the coloaded photosensitizers triggered potent photodynamic therapy effects and induced immunogenic cell death, which worked synergistically with PROTACs toward eliciting a robust antitumor immune response. In a mouse model of lung cancer, primary, distant, and lung metastatic tumors were significantly suppressed. This work highlights the potential of nano-PROTACs for degrading target proteins and facilitating combination photodynamic immunotherapy toward expanding PROTAC applications in cancer therapy.

p53 transcriptionally activates DCP1B to suppress tumor progression and enhance tumor sensitivity to PI3K blockade in non-small cell lung cancer

Non-small cell lung cancer (NSCLC), which accounts for approximately 85% of lung cancer patients, is characterized by its aggressive nature and poor prognosis. In this study, we identify decapping mRNA 1B (DCP1B) as a tumor suppressor gene that is transcriptionally regulated by p53. DCP1B is found to inhibit the growth and migration of NSCLC cells. Consistently, the level of DCP1B expression is decreased in NSCLC tissues, and its low expression is associated with NSCLC patients' unfavorable outcomes. Mechanistic investigations reveal that DCP1B promotes the turnover of mitogen-activated protein kinase 4 (MAPK4) mRNA, and the activation of p53 reduces the expression level of MAPK4 partially through DCP1B. Notably, overexpression of MAPK4 can drive AKT phosphorylation independent of phosphoinositide 3-kinase (PI3K), thus neutralizing the anti-tumor activity of the PI3K inhibitor in NSCLC cells. Moreover, the p53 agonist combined with the PI3K inhibitor can suppress NSCLC proliferation synergistically in vitro and in vivo. Collectively, this study not only uncovers the function and mechanism of the p53-DCP1B-MAPK4 axis in suppressing NSCLC progression but also suggests a promising combination strategy for treating NSCLC.

Multi-omic profiling in breast cancer: utility for advancing diagnostics and clinical care

INTRODUCTION

Breast cancer remains a major global health challenge. While advances in precision oncology have contributed to improvements in patient outcomes and provided a deeper understanding of the biological mechanisms that drive the disease, historically, research and patients' allocation to treatment have heavily relied on single-omic approaches, analyzing individual molecular dimensions such as genomics, transcriptomics, or proteomics. While these have provided deep insights into breast cancer biology, they often fail to offer a complete understanding of the disease's complex molecular landscape.

AREAS COVERED

In this review, the authors explore the recent advancements in multi-omic research in the realm of breast cancer and use clinical data to show how multi-omic integration can offer a more holistic understanding of the molecular alterations and their functional consequences underlying breast cancer.

EXPERT OPINION

The overall developments in multi-omic research and AI are expected to complement precision diagnostics through potentially refining prognostic models, and treatment selection. Overcoming challenges such as cost, data complexity, and lack of standardization is crucial for unlocking the full potential of multi-omics and AI in breast cancer patient care to enable the advancement of personalized treatments and improve patient outcomes.

Integrating network pharmacology and experimental validation to explore the potential mechanism by which resveratrol acts on osimertinib resistance in lung cancer

Globally, osimertinib resistance has been a long-term challenge. Resveratrol, a naturally occurring polyphenolic compound found in various plants, has the potential to modulate multidrug resistance mechanisms. However, the specific role of resveratrol in delaying osimertinib resistance in lung cancer is still unclear. The present study aimed to investigate the therapeutic effects and underlying mechanisms of resveratrol in delaying osimertinib resistance. Accordingly, the corresponding targets of resveratrol were screened through the Traditional Chinese Medicine Systems Pharmacology database. Similarly, the corresponding targets for osimertinib resistance were mined from the GeneCards database. A protein-protein interaction network was subsequently constructed to pinpoint key hub genes that resveratrol may target to delay resistance. Molecular docking analysis was then employed to assess the binding energy between the predicted key targets and resveratrol. Finally, in vitro experiments were performed to validate the results. Ultimately, 13 potential therapeutic targets of resveratrol related to delaying osimertinib resistance were identified. Kyoto Encyclopedia of Genes and Genomes analysis suggested that the effects of resveratrol may be associated with the apoptotic pathway. Molecular docking revealed that resveratrol has good binding affinities with MCL1 and BCL2L11. In vitro experiments confirmed that resveratrol inhibited the proliferation of osimertinib-resistant cells and upregulated the expression of BCL2L11. In conclusion, resveratrol may promote apoptosis by targeting BCL2L11 to delay osimertinib resistance.

RELAY: Final Overall Survival for Erlotinib Plus Ramucirumab or Placebo in Untreated, EGFR-Mutated Metastatic NSCLC

INTRODUCTION

RELAY, a global double-blind, placebo-controlled phase 3 study (NCT02411448) found statistically significant improvement in progression-free survival (primary end point) for ramucirumab (RAM) plus erlotinib (ERL) (RAM + ERL) in patients with untreated EGFR-mutated metastatic NSCLC (hazard ratio [HR] = 0.59, 95% confidence interval [CI]: 0.46-0.76, p < 0.0001; median progression-free survival: 19.4 versus 12.4 mo). Here, we report the final overall survival (OS; secondary end point) outcomes for the intention-to-treat population.

METHODS

Between January 2016 and February 2018, 449 eligible patients with an EGFR exon 19del or L858R mutation and no central nervous system metastases were randomized (1:1) to ERL (150 mg/day) with RAM (10 mg/kg every two weeks, N = 224) or placebo (N = 225).

RESULTS

At data cutoff, 297 deaths were reported (overall event rate = 66%), with a median follow-up of 45.1 months (interquartile range: 26.7-71.2), an OS HR of 0.98 (95% CI: 0.78-1.24, p = 0.864), and median OS of 51.1 months (RAM + ERL) and 46.0 months (placebo + ERL). Outcomes in subsets of patients with poor prognosis (L858R or TP53 co-mutation) suggest a directional improvement in OS (L858R: HR = 0.87, 95% CI: 0.62-1.22; exon 19del: HR = 1.13, 95% CI: 0.83-1.55; TP53 co-mutation: HR = 0.83, 95% CI: 0.58-1.19; TP53-wild-type: HR = 1.22, 95% CI: 0.87-1.72). Treatment-emergent T790M rates were similar between arms. Over 80% of patients received post-study discontinuation therapy (>50% received osimertinib in comparable numbers between arms). The safety profile for RAM + ERL was consistent with previous reports with no increased toxicity over time or new safety signals observed.

CONCLUSION

In RELAY, OS was not significantly improved with similar long OS durations in both treatment arms.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov Identifier: NCT02411448.

The role of TIGIT-CD226-PVR axis in mediating T cell exhaustion and apoptosis in NSCLC

The treatment of non-small cell lung cancer (NSCLC) remains a critical challenge in oncology, primarily due to the dysfunction and exhaustion of T cells within the tumor microenvironment, which greatly limits the effectiveness of immunotherapy. This study investigates the regulatory role of the T cell immunoglobulin and ITIM domain (TIGIT)-CD226-PVR signaling axis in the exhaustion and apoptosis of cluster of differentiation (CD)27+/CD127+T cells in NSCLC. Utilizing single-cell sequencing technology, we conducted a comprehensive gene expression analysis of T cells in a mouse model of NSCLC. Bioinformatics analysis revealed that the TIGIT-CD226-PVR signaling axis is highly active in the CD27+/CD127+T cell subset and is closely associated with their functional decline and exhaustion. In vitro experiments further demonstrated that inhibiting the TIGIT-PVR pathway while activating the CD226-PVR pathway significantly restored T cell proliferation and effector function. Importantly, in vivo studies showed that targeting this axis can significantly alleviate T cell exhaustion, enhance their cytotoxicity against NSCLC cells, and promote apoptosis, thereby improving the efficacy of immunotherapy.

EGFR tyrosine kinase inhibitor ZZC4 overcomes acquired resistance to gefitinib

Despite the tremendous progress of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) development, acquired resistance mechanisms have limited their efficacy in treating non-small cell lung cancer (NSCLC). To overcome these limitations, novel EGFR-TKIs are needed. In our previous study, we presented ZZC4 as a potent EGFR-TKI. In this study, we developed NSCLC cells resistant to EGFR-TKI gefitinib and osimertinib and assessed the effect and mechanism of action of ZZC4 on those cells. HCC827 cells were cultured with gefitinib in a concentration-escalation manner to achieve HCC827 gefitinib-resistant (HCC827-GR) cells after 6 months of treatment. Then, the effect of ZZC4 was assessed at the cellular and animal levels. To understand ZZC4's mechanism of action, the proteome alteration induced by ZZC4 on the resistant cell line was compared to the parental HCC827 cells using comparative proteomics. The result showed that gefitinib's IC50 on HCC827 was 533 nM, approximately 80 times its IC50 on normal cells (7.6 nM), confirming its resistance to HCC827 cells. The obtained resistant cells were treated with ZZC4, which potently suppressed the resistant cells' proliferation with an IC50 of 0.1 nM. In tumor-bearing mice, ZZC4 also suppressed the growth of HCC827-GR cell tumors with an inhibition ratio of 82 % at ZZC4 4 mg/kg. Further, the proteomic analysis revealed that ZZC4 inhibited HCC827-GR cell growth by upregulating CDKN1B and downregulating CCNA2 and CHEK1. In conclusion, ZZC4 overcomes resistance to gefitinib by altering the cell cycle pathway.

Ivacaftor, a CFTR potentiator, synergizes with osimertinib against acquired resistance to osimertinib in NSCLC by regulating CFTR-PTEN-AKT axis

Osimertinib, a third-generation epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), has demonstrated significant clinical benefits in the treatment of EGFR-mutated non-small cell lung cancer (NSCLC). However, inevitable acquired resistance to osimertinib limits its clinical utility, and there is a lack of effective countermeasures. Here, we established osimertinib-resistant cell lines and performed drug library screening. This screening identified ivacaftor, a cystic fibrosis transmembrane conductance regulator (CFTR) potentiator, as a synergistic enhancer of osimertinib-induced anti-tumor activity both in vitro and in vivo. Mechanistically, ivacaftor facilitated the colocalization of CFTR and PTEN on the plasma membrane to promote the function of PTEN, subsequently inhibiting the PI3K/AKT signaling pathway and suppressing tumor growth. In summary, our study suggests that activating CFTR enhances osimertinib-induced anti-tumor activity by regulating the PTEN-AKT axis. Furthermore, ivacaftor and osimertinib constitute a potential combination strategy for treating osimertinib-resistant EGFR-mutated NSCLC patients.

Unraveling the kinase code: Role of protein kinase in lung cancer pathogenesis and therapeutic strategies

Lung cancer is a prominent cause of cancer-related deaths globally, prompting exploration into the molecular pathways governing cancer cell signaling. Recent insights highlight the critical role of kinases in carcinogenesis and metastasis, particularly in non-small cell lung cancer (NSCLC), where protein kinases significantly contribute to drug resistance. These diverse enzymes catalyze protein phosphorylation and are implicated in cancer through misregulated expression, amplification, aberrant phosphorylation, mutations, and chromosomal translocations. Amplifications of kinases serve as important diagnostic, prognostic, and predictive biomarkers across various cancers. Notably, the Phosphatidylinositol 3-kinase (PI3K)/AKT pathway is crucial for the survival and proliferation of tumor cells. Novel therapeutic approaches are being explored to precisely target these pathways. Peptide-based therapies offer specificity and reduced toxicity compared to conventional treatments, while gene therapy targets abnormal genetic expressions. Advances in nanotechnology and CRISPR/Cas9 systems enhance gene delivery methods, holding promise for targeting specific molecular pathways in lung cancer treatment and minimizing systemic toxicity.

A novel mesenchymal epithelial transition (MET) inhibitor, CB538, relieves acquired resistance in EGFR-mutated MET-amplified non-small cell lung cancer

Background

Osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is the first-line standard therapy for metastatic EGFR-mutated non-small cell lung cancer (NSCLC). Although osimertinib is effective, it's durable response is invariably limited by the emergence of acquired resistance. Mesenchymal epithelial transition (MET) amplification is a frequent mechanism in patients with EGFR-mutated NSCLC who are resistant to EGFR-TKIs. Consequently, combined treatment with EGFR-TKIs and MET-TKIs has been explored as a strategy for overcoming this resistance. The current study aimed to explore the single and combination inhibition effect of CB538, a novel MET inhibitor in MET-activated, EGFR-mutant NSCLC cells.

Methods

The cellular inhibitory effects of single and co-treatment of CB538 with EGFR-TKIs were evaluated in the established EGFR-TKI-resistant cells [PC9/ER (erlotinib resistance), HCC827/OR (osimertinib resistance)]. The preclinical activities of CB538 were investigated by evaluating in vitro kinase activity, cell growth, and Western blotting of phosphorylated MET and downstream signaling molecules in MET-activated, EGFR-TKI-resistant cells. Cell viability was examined by MTT and colony formation. The inhibition of migration was determined by wound-healing assay. A xenograft tumor model was employed to investigate in vivo HCC827/OR cell growth in BALB/c nude mice.

Results

We confirmed that activated MET/Axl signaling pathways and EMT-related proteins were inhibited by CB538 in established EGFR-TKI-resistant NSCLC cells. CB538, a novel c-MET inhibitor, decreased the growth, migration, and invasive properties of these EGFR-TKI-resistant NSCLC cells. CB538 also inhibited tumor growth and expression of activated proteins (MET and Axl) in in vivo HCC827/OR xenograft model.

Conclusions

Additional treatment with CB538 enhanced sensitivity to EGFR-TKIs in two EGFR-TKI-resistant NSCLC cells by inhibiting EGFR/MET/Axl pathway axis. Overall, the treatment effects of CB538 were confirmed to relieve EGFR-TKI-driven resistance in EGFR-mutant NSCLC cells.

Piperlongumine overcomes osimertinib resistance via governing ubiquitination-modulated Sp1 turnover

Non-small cell lung cancer (NSCLC) is a common cause of cancer-related deaths worldwide, and its incidence has been increasing in recent years. While targeted therapies like osimertinib, an epidermal growth factor receptor tyrosine kinase inhibitor, have brought about notable improvements in patient outcomes for advanced NSCLC, the challenge of acquired drug resistance persists. Here, we found that cellular mesenchymal-epithelial transition factor (c-Met) was highly expressed in osimertinib-resistant cells, and depletion of c-Met markedly inhibited the growth of osimertinib-resistant cells ex vivo and in vivo, suggesting that c-Met is a potential target to address osimertinib resistance. Through a screening process using a natural product compound library, we identified piperlongumine as a potent inhibitor to overcome osimertinib resistance. Furthermore, the combined treatment of piperlongumine and osimertinib exhibited robust antitumor effects in resistant cells, partially restoring their sensitivity to osimertinib. Additionally, we discovered that piperlongumine could enhance the interaction between E3 ligase RNF4 and Sp1, inhibit the phosphorylation of Sp1 at Thr739, facilitate the ubiquitination and degradation of Sp1, lead to c-Met destabilization, and trigger intrinsic apoptosis in resistant cells. In summary, our study sheds light on the potential of piperlongumine in overcoming osimertinib resistance, offering new strategies and perspectives for the clinical management of drug-resistant NSCLC.

Anti-EGFR therapy can overcome acquired resistance to the third-generation ALK-tyrosine kinase inhibitor lorlatinib mediated by activation of EGFR

Non-small cell lung cancer (NSCLC) is a leading cause of cancer-related mortality. Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) are standard treatments for EML4-ALK-positive NSCLC, but resistance to these agents remains a challenge. This study aimed to determine the mechanisms of acquired resistance to the third-generation ALK-TKI lorlatinib. Lorlatinib-resistant cell lines were established by prolonged exposure to a high concentration of lorlatinib. Activation of epidermal growth factor receptor (EGFR) caused by a decrease in endocytosis and degradation of protein was demonstrated to play an essential role in acquired resistance to lorlatinib. The interaction between the EGFR and ALK was investigated to identify binding sites and conformational changes in ALK. We performed high-throughput compound screening using a small-molecule drugs library comprising 510 antitumor agents in an effort to discover small-molecule compounds that target EGFR in lorlatinib-resistant cells. Combination treatment with ALK-TKI and anti-EGFR agents suppressed acquired resistance to ALK-TKIs caused by activation of EGFR in vitro and in vivo, suggesting that the combination of lorlatinib and an anti-EGFR agent could be effective in patients with lorlatinib-resistant NSCLC. This research provides insights into the mechanism of resistance to lorlatinib and suggests that it can be overcome by anti-EGFR treatment, offering a promising approach for treating resistance to lorlatinib mediated by EGFR activation in patients with ALK-positive NSCLC.

Rapamycin combined with osimertinib alleviated non-small cell lung cancer by regulating the PARP, Akt/mTOR, and MAPK/ERK signaling pathways

Backgrounds

Non-small cell lung cancer (NSCLC), one kind of common malignant tumor, is accompanied by high morbidity and mortality. The effects and related mechanisms of rapamycin (Rapa) combined with osimertinib (Osi) in treating NSCLC are still unclear. Therefore, this study aims to investigate the effects and related mechanisms of Rapa combined with Osi on NSCLC.

Methods

In A549 and PC-9 cells, the Cell Counting Kit-8 (CCK-8) assay was used to select the optimal administrative concentrations of Rapa and Osi and evaluate the cell viability. The Transwell assay and flow cytometry were used to determine the migration, cell cycle, apoptosis, and the level of Reactive Oxygen Species (ROS), respectively. The protein and mRNA expression level of Matrix Metalloproteinase-9 (MMP9), Caspase-3, Microtubule-Associated Protein 1 Light Chain 3 II/I (LC3 II/I), beclin1, Sequestosome 1 (p62), Poly (ADP-ribose) Polymerase (PARP), Mitogen-Activated Protein Kinase (MAPK), Extracellular Signal-Regulated Kinase (ERK), Protein Kinase B (Akt), and Mammalian Target of Rapamycin (mTOR) was determined by Western blot and Quantitative Reverse Transcription Polymerase Chain Reaction (qRT-PCR).

Results

The optimal administrative concentrations of Rapa and Osi were 0.5 μM and 1 μM, respectively. Rapamycin combined with Osimertinib significantly decreased the viability of cells, the quantity of migrated cells, the levels of ROS, as well as the mRNA and protein expression levels of MMP9 and p62, Caspase-3, LC3 II/I, beclin1. The combination of the two drugs is markedly more effective than the use of drugs alone.

Conclusion

In conclusion, the study demonstrated that Rapamycin combined with Osimertinib can inhibit the cell migration, regulate the cell cycle, promote the autophagy and apoptosis, increase the ROS level and regulate the PARP, MAPK/EKR, and Akt/mTOR pathways in A549 and PC-9 cells, providing a novel theoretical basis for their clinical treatment of NSCLC.

Comprehensive transcriptome, miRNA and kinome profiling identifies new treatment options for personalized lung cancer therapy

BACKGROUND

Basic research identified oncogenic driver mutations in lung cancer (LC). However, <10% of patients carry driver mutations. Thus, most patients are not recommended for first-line kinase inhibitor (KI)-based therapies. Through enabling technologies and bioinformatics, we gained deep insight into patient-specific signalling networks which permitted novel KI-based treatment options in LC.

METHODS

We performed molecular pathology, transcriptomics and miRNA profiling across 95 well-characterized LC patients. We confirmed results based on cross-linked immunoprecipitation-sequencing data, and used N = 524 adeno- and 497 squamous cell carcinomas as validation sets. We employed the PamGene platform to identify aberrant kinases, validated the results by evaluating independent siRNA and CRISPR-mediated mRNA knockdown studies in human LC cell lines.

RESULTS

Transcriptomics revealed 439, 1240, 383 and 320 significantly upregulated genes, respectively, for adeno-, squamous, neuroendocrine and metastatic cases, and there are 1092, 1477, 609 and 1267 downregulated DEGs. Based on gene enrichment analysis and experimentally validated miRNA-gene interactions, we constructed regulatory networks specific for adeno-, squamous, neuroendocrine and metastatic LC. Molecular profiling discovered 137 significantly upregulated kinases (range 2-26-fold) of which 65 and 72, respectively, are tyrosine and serine-threonine kinases while 6 kinases carry driver mutations. Meanwhile, there are 21 kinases commonly upregulated irrespective of the histological type of LC. Bioinformatics decoded networks in which kinases function as master regulators. Typically, the networks consisted of 14, 9, 16 and 19 highly regulated kinases in adeno-, squamous, neuroendocrine and metastatic LC. Inhibition of kinases which function as master regulators disrupted the signalling networks, and their gene knock-down studies confirmed inhibition of cell proliferation in a panel of human LC cell lines. Additionally, the proposed molecular profiling enables KI-based therapies in patients with acquired drug resistance.

CONCLUSIONS

Our study broadens the perspective of KI-based therapies in LC, and we propose a framework to overcome acquired drug resistance.

Design, Synthesis and Evaluation of Novel Cyclopropanesulfonamide Derivatives for the Treatment of EGFRC797S Mutation in Non-Small Cell Lung Cancer

Background

The 797S mutation in EGFR disrupts the covalent binding of third-generation inhibitors, causing drug resistance. Currently, no clinically drug fully overcomes this resistance.

Methods

We designed and synthesised a novel EGFR C797S-targeted inhibitor-5d by introducing structures such as cyclopropyl and sulfonamide with Brigatinib as the lead compound; we identified the target of action by ELISA and molecular docking, and tested its anti-tumor activity and safety in vivo and vitro, as well as its effects on cell cycle, apoptosis and DNA damage.

Results

It was found that there were 10 new small-molecule inhibitors and compound 5d was identified as highly selective with low toxicity. WB confirmed 5d's inhibition of EGFR and m-TOR pathways. Mechanistic studies revealed 5d induced cell cycle arrest in G2/M phase caused DNA damage and cell apoptosis, increasing apoptotic protein cleaved caspase-3 levels. It also inhibited growth in PC9 cells with an EGFRdel19 mutation. Importantly, 5d also demonstrated superior anti-tumor activity in vivo and was superior to the positive control Brigatinib.

Conclusion

We concluded that cyclopropylsulfonamide 5d derivatives induce cell cycle arrest, apoptosis, and DNA damage by regulating tumor-related genes, thereby inhibiting the proliferation of C797S mutated lung cancer cells.

Rational Design of a Potent, Selective, and Metabolically Stable CDK9 Inhibitor to Counteract Osimertinib Resistance through Mcl-1 Suppression and Enhanced BRD4 Co-Targeting

Overcoming osimertinib resistance in NSCLC treatment remains a significant clinical challenge. CDK9 has emerged as a promising target due to its critical role in sustaining oncogenic transcriptional programs, particularly via Mcl-1 regulation. Herein, we report the structure-guided optimization of a previously identified CDK9 inhibitor (Z11), resulting in the discovery of T7, a potent, selective, and metabolically stable candidate (IC50 = 1.2 nM). T7 effectively suppressed cell proliferation, reduced colony formation, and induced apoptosis in Osimertinib-resistant NSCLC cells by downregulating Mcl-1. Furthermore, T7 significantly inhibited the growth of resistant organoids and demonstrated marked antitumor efficacy in a xenograft model. Notably, combining T7 with the BRD4 inhibitor JQ1 further enhanced antitumor activity both in vitro and in vivo, revealing a complementary therapeutic strategy. These findings identify T7 as a promising next-generation CDK9 inhibitor for addressing Osimertinib resistance in NSCLC and underscore the potential of transcriptional cotargeting approaches to improve clinical outcomes.

Amivantamab plus lazertinib vs. osimertinib in first-line EGFR-mutant advanced non-small cell lung cancer

INTRODUCTION

The first-line treatment landscape for patients with NSCLC harboring sensitizing EGFR mutations is rapidly evolving. Initially, osimertinib was the one and only option over earlier generation EGFR inhibitors based on the positive PFS and OS results from the FLAURA study.

AREAS COVERED

This paper reviews and compares the pivotal studies that led to the approval of combination treatment with a focus on the efficacy and safety of amivantamab plus lazertinib in the front-line setting. The literature reviewed in this paper primarily includes key studies published in well-established journals and oncological conferences, such as ASCO, ESMO, and NEJM, between 2018 and 2024.

EXPERT OPINION

Recent advancements, including the results of FLAURA-2 and MARIPOSA, have introduced combination therapies that demonstrate enhanced efficacy.

Multifaceted Approaches in Epithelial Cell Adhesion Molecule-Mediated Circulating Tumor Cell Isolation

Circulating tumor cells (CTCs) are pivotal in cancer metastasis and serve as valuable biomarkers for diagnosis, prognosis, and treatment monitoring. Traditional CTC capture methods predominantly utilize the epithelial cell adhesion molecule (EpCAM) as a marker for isolation. However, the heterogeneity of these circulating cells and the epithelial-to-mesenchymal transition process (wherein epithelial cells acquire mesenchymal characteristics) limit the efficacy of EpCAM-based capture techniques. In this paper, we critically review the role of the EpCAM in CTC capture, explore the impact of epithelial-to-mesenchymal transition on EpCAM expression, and discuss alternative biomarkers and strategies to enhance CTC isolation. By evaluating the limitations of EpCAM-mediated capture and the challenges posed by epithelial-to-mesenchymal transition, we aim to provide insights into the development of more comprehensive liquid biopsy approaches for cancer management.

Rationally Designed Cell Membrane Biomimetic Biosensing Platform for the Binding Analysis of Drugs with Intracellular Kinase Domain of Epidermal Growth Factor Receptor

Biosensing technologies have demonstrated significant potential in exploring the binding of drugs to receptor tyrosine kinases (RTKs). As a typical transmembrane receptor, there are still several shortcomings in the utilization of the intracellular kinase domain of RTKs, the primary action site of small-molecule inhibitors, resulting in insufficient binding and unclear action sites, which impair the efficiency and accuracy of biosensing. Herein, using epidermal growth factor receptor (EGFR) as an example, we reported a biosensing platform based on cell membrane camouflage technology for evaluating drugs binding to the intracellular kinase domain of EGFR. The azide-functionalized cell membranes modified through glucose metabolism were reverse-coated onto alkyne-functionalized magnetic nanoparticles via bioorthogonal reaction (CMRMNPs), therefore effectively exposing the intracellular kinase domain of EGFR without damage. To construct the biosensing platform, a small-molecule fluorescent probe derived from the gefitinib pharmacophore (GN probe) was further synthesized and incubated with CMRMNPs. This strategy facilitated the efficient localization of the GN probe within the intracellular kinase domain of EGFR. Ultimately, this approach was successfully implemented to evaluate the binding of three inhibitors with EGFR. This study provides a viable strategy for constructing biomimetic biosensors with a defined cell membrane orientation and offers novel insights and methodologies for the study of drug binding with the intracellular kinase regions of RTKs.

Non-small cell lung cancer and the tumor microenvironment: making headway from targeted therapies to advanced immunotherapy

Over the past decades, significant progress has been made in the understanding of non-small cell lung cancer (NSCLC) biology and tumor progression mechanisms, resulting in the development of novel strategies for early detection and wide-ranging care approaches. Since their introduction, over 20 years ago, targeted therapies with tyrosine kinase inhibitors (TKIs) have revolutionized the treatment landscape for NSCLC. Nowadays, targeted therapies remain the gold standard for many patients, but still they suffer from many adverse effects, including unexpected toxicity and intrinsic acquired resistance mutations, which lead to relapse. The adoption of immune checkpoint inhibitors (ICIs) in 2015, has offered exceptional survival benefits for patients without targetable alterations. Despite this notable progress, challenges remain, as not all patients respond favorably to ICIs, and resistance to therapy can develop over time. A crucial factor influencing clinical response to immunotherapy is the tumor microenvironment (TME). The TME is pivotal in orchestrating the interactions between neoplastic cells and the immune system, influencing tumor growth and treatment outcomes. In this review, we discuss how the understanding of this intricate relationship is crucial for the success of immunotherapy and survey the current state of immunotherapy intervention, with a focus on forthcoming and promising chimeric antigen receptor (CAR) T cell therapies in NSCLC. The TME sets major obstacles for CAR-T therapies, creating conditions that suppress the immune response, inducing T cell exhaustion. To enhance treatment efficacy, specific efforts associated with CAR-T cell therapy in NSCLC, should definitely focus TME-related immunosuppression and antigen escape mechanisms, by combining CAR-T cells with immune checkpoint blockades.

Catalytic Lysine745 targeting strategy in fourth-generation EGFR tyrosine kinase inhibitors to address C797S mutation resistance

Overcoming resistance to third-generation tyrosine kinase inhibitors (TKIs) such as Osimertinib, particularly due to the emergence of the C797S mutation, remains a key challenge in non-small cell lung cancer (NSCLC) therapy. This review highlights recent advancements in the development of fourth-generation EGFR inhibitors that specifically target the catalytic Lys745 residue, aiming to overcome resistance associated with Osimertinib. Both covalent and non-covalent inhibitors targeting Lys745 were explored, using warheads like sulfonyl fluoride, phosphine oxides, esters, and trisubstituted imidazoles. Sulfonyl fluoride was particularly effective in forming covalent bonds with Lys745, while non-covalent analogues demonstrated flexibility with reduced off-target effects. The manuscript highlights the importance of warhead design, molecular docking, protein XRD study and structure-activity relationships (SAR) for optimizing Lys745-targeting inhibitors. The study suggests that hybrid scaffolds combining key pharmacophoric features from Osimertinib and Brigatinib along with Lys745 targeting warheads, could enhance selectivity and potency. Future efforts should focus on refining bioavailability, identifying new scaffolds by employing drug design strategies. Fourth-generation TKIs targeting Lys745 offer a novel therapeutic avenue, potentially overcoming mutation-induced resistance and improving NSCLC treatment outcomes. This approach represents a critical advancement toward durable clinical responses in patients with drug-resistant cancer.

Silencing of LINC01278 promotes sensitivity of non-small cell lung cancer cells to osimertinib by targeting miR-324-3p/ZFX axis

Osimertinib has been demonstrated to be effective for improving the prognosis of patients with epidermal growth factor receptor mutation-positive lung cancer. However, osimertinib resistance inevitably emerges throughout the treatment course. This study explored the function and mechanism of long noncoding RNA LINC01278 in osimertinib-resistant NSCLC cells. Osimertinib-resistant non-small cell lung cancer (NSCLC) cells were established by treating PC9 and HCC827 cells with increasing doses of osimertinib for over 6 months. LINC01278 expression in parental and drug-resistant cells (PC9-OR and HCC827-OR) was measured by polymerase chain reaction. Cell counting kit 8 assays were used to examine cell viability and half-maximal inhibitory concentration values. The effects of LINC01278 knockdown on cell proliferation and apoptosis were measured by colony formation assays and flow cytometry. A luciferase reporter assay was performed to verify the interaction between LINC01278 and miR-324-3p or the binding ability between miR-324-3p and ZFX. Protein levels of ZFX and apoptotic markers in NSCLC cells were measured by western blotting. As shown by experimental results, LINC01278 was highly expressed in osimertinib-resistant NSCLC cells compared to its expression in parental cells. The silencing of LINC01278 improved the sensitivity of drug-resistant cells towards osimertinib. LINC1278 depletion inhibited osimertinib-resistant cell proliferation while promoting cell apoptosis. LINC01278 interacted with miR-324-3p to regulate ZFX expression. ZFX could be targeted by miR-324-3p in PC9-OR and HCC827-OR cells. ZFX overexpression counteracted the suppressive impact of LINC01278 silencing on the malignant behavior of PC9-OR and HCC827-OR cells. In conclusion, LINC01278 knockdown alleviates osimertinib resistance of NSCLC cells by regulating downstream miR-324-3p and ZFX.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10616-024-00673-8.

RBM15 facilitates osimertinib resistance of lung adenocarcinoma through m6A-dependent epigenetic silencing of SPOCK1

Lung cancer is the leading cause of cancer-related mortality globally. N6-methyladenosine (m6A) is the most abundant modification in mammalian mRNA and is involved in the biological regulation of tumors, including lung cancer. However, the role of m6A-related proteins, such as RNA-binding motif protein 15 (RBM15), in lung cancer progression remains largely unknown. Our study indicated that RBM15 is significantly overexpressed in lung adenocarcinoma, serving as an independent prognostic factor for poor outcomes and facilitating tumor cell proliferation and migration. RBM15 was markedly elevated in patients with EGFR mutations, correlating with a poorer prognosis, while it had negligible prognostic value in EGFR wild-type patients. As EGFR-tyrosine kinase inhibitors (TKIs) are the standard treatment for patients with EGFR mutations, we subsequently determined that RBM15 drives osimertinib resistance via a novel mechanism: enhancing m6A modification of cwcv- and kazal-like domains proteoglycan 1 (SPOCK1) mRNA, promoting epithelial-mesenchymal transition-mediated osimertinib resistance through a bypass activation pathway. These findings were validated in osimertinib-resistant H1975 cells and organoids from patients with osimertinib-resistant lung adenocarcinoma. Furthermore, the RBM15-SPOCK1 axis was activated in drug-tolerant persister cells, indicating that early targeting of RBM15 during EGFR-TKI treatment could dramatically extend the patient response and benefit from TKI therapy. Our results emphasize the critical role of RBM15 in reversing EGFR-TKI resistance and propose it as a promising therapeutic target for prolonging TKI treatment benefits in patients with lung adenocarcinoma.

Addressing Clinical Limitations of Glutaminase Inhibitors: Novel Strategies for Osimertinib-Resistant Lung Cancer by Exploiting Glutamine Metabolic Dependency

Overcoming acquired resistance to Osimertinib remains a critical challenge in treating NSCLC. This research indicates that Osimertinib-resistant cells exhibit a strong dependence on glutamine metabolism. However, targeting GLS1 shows limited anticancer effects, probably because it cannot fully block the glutamine metabolic pathway. The investigation reveals that a more effective strategy involves simultaneously inhibiting both ASCT2 and GLS1. After confirming the efficacy of this dual-targeting approach against Osimertinib-resistant cells in preclinical models, the potential of utilizing a broad-spectrum glutamine metabolism antagonist is further explored to achieve superior antitumor efficacy. DON, broad-spectrum glutamine antagonist, presents toxicity issues. Herein, the high NQO1 expression in Osimertinib-resistant NSCLC cells is leveraged to design an NQO1-responsive DON prodrug, 10e (LBJ-10e). This prodrug demonstrates superior safety compared to natural DON and greater antitumor activity against resistant tumors compared to the clinical phase II drug DRP104. These findings may address the clinical limitations of GLS1 allosteric inhibitors and underscore prodrug strategies in effectively treating Osimertinib-resistant lung cancer, providing a foundation for future clinical trials.

A Novel DNA Repair-Gene Model to Predict Responses to Immunotherapy and Prognosis in Patients With EGFR-Mutant Non-Small Cell Lung Cancer

BACKGROUND

The epidermal growth factor receptor mutant (EGFRm) non-small cell lung cancer (NSCLC) has a unique "cold" immune profile. DNA damage repair (DDR) genes are closely related to tumorigenesis and the effectiveness of immunotherapy in many tumors. However, the role and mechanism of DDR in the genesis and progression of EGFRm NSCLC remain unclear.

METHODS

This study included 101 EGFRm NSCLC samples from The Cancer Genome Atlas (TCGA) dataset and a GSE31210 dataset (external set) from the GEO database. Cluster analysis was used to identify different subtypes of EGFRm NSCLC based on the expression of DDR genes. Univariate and LASSO regression analysis was used to develop a DDR-based predictive model. The prognostic significance of this model was assessed using Cox regression, Kaplan-Meier, and receiver operating characteristic (ROC) curve analyses. Bioinformatics analysis was performed to investigate the clinicopathological characteristics and immune profiles associated with this model. In vitro experiment was performed to testify the role of DDR genes in EGFRm NSCLC.

RESULTS

We identified two subtypes of EGFRm NSCLC: DDR-activated and DDR-suppressed. The DDR-activated subtype showed more aggressive clinical behavior and poorer prognosis and was more responsive to immunotherapy. A prognostic model for EGFRm NSCLC was constructed using four DDR genes: CAPS, FAM83A, IGLV8-61, and SLC7A5. The derived risk score could serve as an independent prognostic indicator. High- and low-risk patients exhibited distinct clinicopathological characteristics, immune profiles, and responses to immunotherapy. The T-cell inflammation and Tumor Immune Dysfunction and Exclusion (TIDE) scores differed between the high- and low-risk subgroups, with both showing enhanced effectiveness of immunotherapy in the low-risk subgroup. Targeted therapy such as BI.2536, an inhibitor of polo-like kinase 1, could be effective for patients with high-risk EGFRm NSCLC. Meanwhile, in vitro detection approved the role of DDR genes in EGFRm NSCLC response.

CONCLUSION

This study demonstrated a diversity of DDR genes in EGFRm NSCLC and developed a predictive model using these genes. This model could assist in identifying potential candidates for immunotherapy and in assessing personalized treatment and prognosis of patients with EGFRm NSCLC.

Pharmacological effects of osimertinib on a chicken chorioallantoic membrane xenograft model with the EGFR exon-19-deleted advanced NSCLC mutation

Non-small cell lung cancer (NSCLC) affects 10-50% of patients with epidermal growth factor receptor (EGFR) mutations. Osimertinib is a third-generation EGFR tyrosine kinase inhibitor (TKI) that radically changes the outcome of patients with tumors bearing EGFR sensitizing or EGFR T790M resistance mutations. However, resistance usually occurs, and new therapeutic combinations need to be explored. The chorioallantoic membrane (CAM) xenograft model is ideal for studying aggressive tumor growth and the responses to complex therapeutic combinations due to its vascularization and complex microenvironment. This study aims to demonstrate the relevance of analyzing a complex therapeutic response to osimertinib treatment, especially through advanced transcriptomic analysis with the CAM model, which has been limited thus far. We engrafted HCC827 cells (EGFR p.E746_A750del) into the CAM model and treated them with various osimertinib doses for 7 days. The study involved supervised multivariate discrimination and ontology analysis of human transcriptional data. We found that CDX tumor growth inversely correlated with osimertinib dosage, with a notable 35% tumor weight reduction at 10 μm. Transcriptomic analysis revealed that osimertinib reduces EGFR pathway activity and its effectors, and dampens chemotaxis, immune recruitment and angiogenesis, indicating that effectiveness extends beyond cellular mechanisms to the tissue level. This was supported by a 15% reduction in blood vessels around the xenograft in osimertinib-treated cases. This study is the first to demonstrate that ontological analysis of transcriptomic data in the CAM model aligns with clinical observations, highlighting the relevance of this methodology for understanding and ameliorating the efficacy of targeted therapy in NSCLC.

A Case of Non-Small Cell Lung Cancer with Mutually Exclusive EGFR and KRAS Mutations

Historically, EGFR and KRAS mutations were believed to be mutually exclusive. However, over the past few years, there have been emerging case reports showing the co-existence of both mutations in a single case. The majority of these co-occurring alterations were detected in samples collected from patients with resistance to tyrosine kinase inhibitor (TKI) treatment, indicating a potential functional role in driving resistance to therapy. These co-occurring tumor genomic alterations are not necessarily mutually exclusive, and evidence suggests that multiple clonal and sub-clonal cancer cell populations can co-exist and contribute to EGFR TKI resistance. We have reported such a case of concomitant EGFR and KRAS mutation in a 64-year-old female. This case highlights the importance of continuous molecular testing in managing NSCLC, especially in cases with rare mutation profiles. The emergence of new mutations during treatment can significantly impact the course of therapy and patient outcomes. In this case, the detection of both EGFR and KRAS mutations guided the selection of an appropriate targeted therapeutic strategy, including the use of Amivantamab.

GRHL2-HER3 and E-cadherin mediate EGFR-bypass drug resistance in lung cancer cells

Epidermal growth factor receptor (EGFR) is a major oncogenic protein, and thus EGFR-targeting therapies are widely used in patients with various types of cancer, including lung cancer. However, resistance to EGFR inhibitors, such as erlotinib, presents a significant challenge in treating lung cancer. In this study, we established an EGFR-independent, erlotinib-resistant (ER) phenotype in lung cancer A549 cells by exposing them to erlotinib for an extended period. The resulting ER cells exhibited a dramatic increase in erlotinib resistance, a decreased EGFR protein level, and enhanced tumor growth, suggesting a robust mechanism bypassing EGFR inhibition. RNA sequencing identified the transcription factor GRHL2 as a critical player in this resistance. GRHL2 was upregulated in ER cells, and its knockdown and knockout significantly reduced erlotinib resistance. Further analysis revealed that GRHL2 upregulates the receptor tyrosine kinase HER3, and that HER3 knockdown similarly decreases the IC50 for erlotinib. Additionally, ER cells showed increased cell-cell adhesion, linked to upregulated E-cadherin. E-cadherin was found to be vital for erlotinib resistance, largely independent of GRHL2, highlighting multiple parallel pathways sustaining resistance. These findings provide a novel mechanism of drug resistance and suggest that combination therapies targeting both GRHL2-HER3 and E-cadherin-mediated pathways may be necessary to overcome erlotinib resistance in lung cancer.

Cancer-associated fibroblasts induce almonertinib resistance in non-small cell lung cancer

BACKGROUND

Almonertinib is the initial third-generation EGFR-TKI in China, but its resistance mechanism is unknown. Cancer-associated fibroblasts (CAFs) are essential matrix components in the tumor microenvironment, but their impact on almonertinib resistance is unknown. This study aimed to explore the correlation between CAFs and almonertinib resistance in non-small cell lung cancer (NSCLC).

METHODS

The anti-cancer effects of almonertinib on NSCLC cells, as well as the reversal of these effects mediated by CAFs, were validated through phenotypic experiments. Differential gene expression analysis, along with GO and KEGG enrichment analyses, was performed to predict the potential mechanisms underlying resistance to third-generation EGFR-TKIs. Finally, qPCR and Western blot analyses were used to explore the signaling pathways by which CAFs induce resistance to almonertinib in NSCLC cells.

RESULTS

Our findings revealed that almonertinib significantly suppressed the invasion, migration, and proliferation of EGFR T790M-mutant NSCLC cells. TGF-β1 successfully induced the differentiation of CAFs and upregulated the expression of CAF markers, including α-SMA and fibroblast activation protein (FAP). Exposure of H1975 cells to almonertinib increased TGF-β1 secretion. Additionally, CAFs enhanced the survival of almonertinib-treated NSCLC cells, whereas normal fibroblasts (NFs) exerted the opposite effect. qPCR analysis demonstrated that the expression of the core molecules of the Hippo pathway, YAP and TAZ, was lower in A549 cells than in H1975 cells, and CAF intervention further reduced YAP/TAZ expression in H1975 cells. Western blot analysis confirmed a significant reduction in YAP/TAZ protein levels in cancer cells treated with CAF-conditioned medium (CAF-CM) compared to those treated with normal control-conditioned medium (NC-CM). Finally, we demonstrated that CAFs induced resistance to almonertinib in NSCLC cells, potentially through a mechanism involving YAP/TAZ.

CONCLUSION

This study demonstrated that H1975 cells stimulated by almonertinib promoted the accumulation of CAFs in NSCLC cells, likely through increased secretion of TGF-β1. The accumulation of CAFs enhanced the survival of NSCLC cells undergoing almonertinib treatment and induced drug resistance. Additionally, the mechanism underlying CAF-induced drug resistance in NSCLC cells was potentially linked to the activation of the YAP/TAZ signaling pathway.

Identification and validation of a metabolic-related gene risk model predicting the prognosis of lung, colon, and breast cancers

Metabolic reprogramming, vital for cancer cells to adapt to the altered microenvironment, remains a topic requiring further investigation for different tumor types. Our study aims to elucidate shared metabolic reprogramming across breast (BRC), colorectal (CRC), and lung (LUC) cancers. Leveraging gene expression data from the Gene Expression Omnibus and various bioinformatics tools like MSigDB, WebGestalt, String, and Cytoscape, we identified key/hub metabolism-related genes (MRGs) and their interactions. The functional characteristics including survival parameters and expression of the key MRGs were analyzed and validated through Gene Expression Profiling Interactive Analysis 2 and qRT-PCR. In addition, we employed machine learning algorithms such as k-nearest neighbours (KNN), support vector regressor (SVR), and extreme gradient boosting (XGBoost) to assess MRGs' effectiveness in predicting overall patient survival. Among 11,384 DEGs analyzed, 540 overlapped across BRC, CRC, and LUC, with 46 MRGs and 20 key/hub MRGs involved in all studied cancer types. Of these, 11 key MRGs were prognostically significant. The qRT-PCR validation of key MRGs in specific cancer cell lines confirmed their expression profiles, with some showing cell-type-specific patterns. SVR exhibited remarkable accuracy in predicting overall survival, emphasizing its clinical utility. Our integrated approach combining bioinformatics analyses and experimental validations underscores the potential of MRGs as biomarkers for metabolic therapies, with machine learning models enhancing predictive capabilities for patient outcomes.

A cohort-based multi-omics identifies nuclear translocation of eIF5B /PD-L1/CD44 complex as the target to overcome Osimertinib resistance of ARID1A-deficient lung adenocarcinoma

BACKGROUND

Osimertinib has emerged as a critical element in the treatment landscape following recent clinical trials. Further investigation into the mechanisms driving resistance to Osimertinib is necessary to address the restricted treatment options and survival advantages that are compromised by resistance in patients with EGFR-mutated lung adenocarcinoma (LUAD).

METHODS

Spatial transcriptomic and proteomic analyses were utilized to investigate the mechanisms of Osimertinib resistance. Co-IP, MS, RNA-seq, ChIP-seq, RIP-seq, and ATAC-seq were performed in cell lines to further explore the mechanism. To validate the findings, in vitro and in vivo molecular experiments were conducted.

RESULTS

We found that the ARID1A deficiency results in resistance to Osimertinib by hindering programmed cell death through the EZH2/PTEN/E2F1 axis. This altered axis influences PD-L1 transcription through E2F1-mediated promoter activation and PD-L1 translation via the MDM2/eIF5B/PD-L1 axis. Subsequently, ARID1A deficiency results in increased expression of eIF5B and Importin-β1, promoting PD-L1 nuclear-translocation. The nuclear PD-L1 (nPD-L1) interacts with CD44, leading to nPD-L1 complex formation, activation of the RASGEF1A promoter, initiation of the Ras pathway, and contributing to Osimertinib resistance. Targeting the transcription, translation and nuclear-translocation of PD-L1 using lipid nanoparticles (LNPs) overcomes ARID1A deficiency-induced resistance.

CONCLUSION

ARID1A deficiency promotes PD-L1 nuclear translocation and induces Osimertinib resistance.

A phase II trial of anlotinib plus EGFR-TKIs in advanced non-small cell lung cancer with gradual, oligo, or potential progression after EGFR-TKIs treatment (CTONG-1803/ALTER-L001)

BACKGROUND

The study is to evaluate the efficacy and safety of combined anlotinib and EGFR-tyrosine kinase inhibitors (TKIs) in patients with advanced non-small cell lung cancer (NSCLC) who had gradual, oligo, or potential progression after previous EGFR-TKIs treatment.

METHODS

We conducted an open-label, single-arm, multicenter, phase II trial in China. Eligible patients were 18-75 years old with histologically or cytologically confirmed NSCLC who were EGFR mutation positive and showed gradual, oligo, or potential progression after EGFR-TKIs. Anlotinib (12 mg/day) was administered orally for 2 weeks and then off 1 week in a 3-week cycle. EGFR-TKIs were continue used. The primary endpoint was progression-free survival (PFS). The secondary endpoints included 6- and 12-month PFS rate, objective response rate (ORR), disease control rate (DCR), overall survival (OS) and safety.

RESULTS

From July 2019 to December 2022, 120 patients were enrolled. The median PFS (mPFS) was 9.1 months (95% CI 6.8-11.7). The PFS rates at 6 and 12 months was 68.5% and 38.8% respectively. For 86 patients with first-line 1st /2nd generation EGFR-TKIs, the mPFS was 9.2 months (95% CI 6.7-12.6). For 32 patients with first-line 3rd generation EGFR-TKIs, the mPFS was 10.3 months (95% CI 6.1-13.3). Overall ORR and DCR were 6.7% (95% CI 2.9-12.7) and 87.5% (95% CI 80.2-92.8), respectively. 52.5% of patients had grade 3 or higher treatment-emergent adverse events (TEAEs).

CONCLUSION

Anlotinib in combination with continuation of EGFR-TKIs prolonged the clinical benefit of EGFR-TKIs, demonstrating favorable survival outcomes and manageable toxicity in NSCLC treated with EGFR-TKIs and had specific progression modes, such as gradual progression.

TRIAL REGISTRATION

NCT04007835.

An acquired CCDC6::RET gene fusion as resistance mechanism for Osimertinib in exon 21 EGFR(L858R)-mutated non-small cell lung cancer and its successful management with Osimertinib and Selpercatinib: a case report and review of literature

Background: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI) are the recommended front-line therapy for treatment-naïve patients with advanced stage EGFR mutated Non-Small Cell Lung Cancer (NSCLC), with better tolerance and outcomes compared to chemotherapy. However, patients inevitably develop resistance to EGFR-TKI. The extent of progression free survival depends on intrinsic or acquired on-target/off-target mechanisms of EGFR-TKI resistance. Overcoming these acquired rearrangements remains challenging in modern precision medicine. In case of disease progression during treatment with an EGFR-TKI, rebiopsy is recommended to search for a potential resistance mechanism. However, the therapeutic potential of these resistance mechanisms represents an unmet need in thoracic oncology. CasePresentation: We present a case of a 78-year-old woman with stage IVB EGFR-mutated NSCLC in whom an acquired RET Gene Fusion was identified as the EGFR-independent resistance mechanism. Additionally, a combined therapy of Osimertinib and Selpercatinib showed a durable oncological response with 14 months of progression free survival in the absence of adverse events. Conclusion: Addition of Selpercatinib to Osimertinib in an EGFR-mutated NSCLC patient with an acquired RET fusion was well tolerated and created a clinical benefit. Further prospective investigation into these novel combination strategies is needed as resistance mechanisms could serve as possible targets for new therapy approaches.

Melittin suppresses aerobic glycolysis by regulating HSF1/PDK3 to increase chemosensitivity of NSCLC

Non-small cell lung cancer (NSCLC), although considered non-immunogenic, is often resistant to chemotherapy agents during the course of treatment in clinical patients. Melittin (C131H229N39O31, CAS: 20449-79-0), the major component of honey bee venom, is a promising anticancer drug. However, the mechanism employed by melittin to reverse chemotherapy resistance of NSCLC cells remains unknown. In this study, the Cell Counting Kit 8, ethynyl deoxyuridine assay, and other assays were utilized to elucidate the melittin effects upon cell proliferation. Proteomics, lung cancer (LC) tissue chip, and Western blot analysis were used to identify potential targets of melittin. A549/DDP cells were employed to investigate the melittin effects against cisplatin resistance. Also, an in vivo animal experiment was conducted to further clarify the regulatory function of melittin towards cisplatin resistance of A549/DDP cells. Results showed that melittin inhibited malignant progression of A549/DDP cells by down-regulation of pyruvate dehydrogenase kinase 3 (PDK3)-mediated aerobic glycolysis and inhibition of heat shock factor 1 (HSF1) expression. The therapeutic effect of melittin was increased by combination with KNK437 and impaired chemotherapy resistance regarding A549/DDP cells via reversing aerobic glycolysis. The in vivo experiments confirmed that melittin incremented A549/DDP cell cisplatin sensitivities. Collectively, the data suggested that melittin suppressed aerobic glycolysis by regulating HSF1/PDK3, which incremented cisplatin sensitivity of A549/DDP cells. It may provide a new treatment method for chemotherapy resistance in clinical NSCLC patients.

High CD38 expression defines a mitochondrial function-adapted CD8+ T cell subset with implications for lung cancer immunotherapy

Despite identifying specific CD8+ T cell subsets associated with immunotherapy resistance, the molecular pathways driving this process remain elusive. Given the potential role of CD38 in regulating CD8+ T cell function, we aimed to investigate the accumulation of CD38+CD8+ T cells in lung cancer and explore its role in immunotherapy resistance. Phenotypic analysis of tumoral CD8+ T cells from both lung cancer patients and immunotherapy-resistant preclinical models revealed that CD38-expressing CD8+ T cells consist of CD38hi and CD38int subsets. These cells exhibited higher expression of exhaustion markers and displayed dysregulated mitochondrial bioenergetics. Notably, increased levels of CD38hiCD8+ T cells in the peripheral, but not central, tumor microenvironment were associated with a favorable response to anti-PD-1 therapy in non-small-cell lung cancer and correlated with the depth of clinical regression. This was evidenced by the greater depletion of CD38hiCD8+ T cells in patients with higher regional CD38hiCD8+ T cell infiltration. In immune checkpoint blockade (ICB)-resistant murine lung cancer models, PD-L1 mAbs alone failed to effectively reduce CD38hiCD8+ T cell levels. Notably, combination therapy with PD-L1 mAbs and EGCG selectively restricted CD38hiCD8+ T cell infiltration and enhanced IFN-γ production, significantly improving survival in this carcinoma model. The restoration of immunotherapy sensitivity was linked to improved mitochondrial function in CD38hiCD8+ T cells, which was validated by the established relationship between IFN-γ production and mitochondrial metabolism. Collectively, our data highlight the role of CD38-coupled mitochondrial dysfunction in promoting CD8+ T cell exhaustion and intrinsic resistance to ICB therapy, thereby offering a rationale for targeting CD38 to enhance the therapeutic efficacy of PD-1 blockade in lung cancer.

Liquid-Liquid Phase Separation in the Prognosis of Lung Adenocarcinoma: An Integrated Analysis

BACKGROUND

Lung adenocarcinoma (LUAD) is a highly lethal malignancy. Liquid- Liquid Phase Separation (LLPS) plays a crucial role in targeted therapies for lung cancer and in the progression of lung squamous cell carcinoma. However, the role of LLPS in the progression and prognosis of LUAD remains insufficiently explored.

METHODS

This study employed a multi-step approach to identify LLPS prognosis-related genes in LUAD. First, differential analysis, univariate Cox regression analysis, Random Survival Forest (RSF) method, and Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression analysis were utilized to identify five LLPS prognosis-related genes. Subsequently, LASSO Cox regression was performed to establish a prognostic score termed the LLPS-related prognosis score (LPRS). Comprehensive analyses were then conducted based on the LPRS, including survival analysis, clinical feature analysis, functional enrichment analysis, and tumor microenvironment assessment. The LPRS was integrated with additional clinicopathological factors to develop a prognostic nomogram for LUAD patients. Immunohistochemical validation was performed on clinical tissue samples to further validate the findings. Finally, the relationship between KRT6A, one of the identified genes, and epidermal growth factor receptor (EGFR) mutations was investigated.

RESULTS

The LPRS was established using five LLPS-related genes: IGF2BP1, KRT6A, LDHA, PKP2, and PLK1. Higher LPRS was closely associated with poor survival outcomes, gender, progression-free survival (PFS), and advanced TNM stage. Furthermore, LPRS emerged as an independent prognostic factor for LUAD. A nomogram integrating LPRS, TNM stage, and age demonstrated remarkable predictive accuracy for prognosis among patients with LUAD. LLPS likely influences LUAD prognosis through the activity of IGF2BP1, KRT6A, LDHA, PKP2, and PLK1. KRT6A exhibits significant upregulation in LUAD, particularly in patients with EGFR mutations.

CONCLUSION

This study introduces a novel LPRS model that demonstrates high accuracy in predicting the clinical prognosis of LUAD. Moreover, the findings suggest that KRT6A may play a critical role in the LLPS-mediated malignant progression of LUAD.

Recent Developments in Tyrosine Kinase Inhibitor-based Nanotherapeutics for EGFR-resistant Non-small Cell Lung Cancer

The advent of drug resistance in response to epidermal growth factor receptor (EGFR)- tyrosine kinase inhibitor (TKI) targeted therapy represents a serious challenge in the management of non-small cell lung cancer (NSCLC). These acquired resistance mutations, attributed to several advanced EGFR mutations and, necessitated the development of new-generation TKIs. Nanomedicine approaches provide a plausible way to address these problems by providing targeted delivery and sustained release, which have demonstrated success in preclinical trials. This review article provides a summary of nano-formulations designed for EGFR-TKI-resistant NSCLC, highlighting their efficacy in both in vitro and in vivo models. These findings reveal insights into the design of nanoparticles and multifunctional nanosystems, offering a potential avenue for efficacious treatment of EGFR-TKIresistant NSCLC.

Regulation of keratinocyte barrier function and inflammatory response by the EGFR-STAT3 Pathway: Potential therapeutic implications of osimertinib and afatinib

The epidermal growth factor receptor (EGFR) signaling pathway is crucial for skin barrier integrity and immune response. This study explores the impact of EGFR inhibitors, osimertinib and afatinib, on keratinocyte function, focusing on keratin (KRT1, KRT17) and tight junction protein (CLDN1, CLDN2, CLDN4) expression in HaCaT cells. Osimertinib significantly increased the mRNA and protein levels of keratins and inflammatory markers, IL-6 and TNF-α, via activation of the EGFR-STAT3 signaling pathway. Co-treatment with recombinant human EGF reversed these changes, suggesting the pathway's modulatory role. These findings underscore the potential therapeutic applications of targeting the EGFR-STAT3 axis in skin barrier dysfunction and inflammatory skin disorders.

Shikonin induces the apoptosis and pyroptosis of EGFR-T790M-mutant drug-resistant non-small cell lung cancer cells via the degradation of cyclooxygenase-2

BACKGROUND

The T790M mutation in the epidermal growth factor receptor (EGFR) gene is the primary cause of resistance to EGFR-tyrosine kinase inhibitor (TKI) therapy in non-small cell lung cancer (NSCLC) patients. Previous research demonstrated that certain traditional Chinese medicine (TCM) monomers exhibit anti-tumor effects against various malignancies. This study aims to investigate the potentials of shikonin screened from a TCM monomer library containing 1060 monomers in killing EGFR-T790M drug-resistant NSCLC cells and elucidate the underlying mechanisms.

METHODS

MTT method was used to screen for the TCM monomers with significant killing effects on H1975 cells carrying the EGFR-T790M mutation. The influences of the identified monomer shikonin on cell growth were determined by the colony formation assay. Annexin-V/PI staining and JC-1 staining were applied to detect the effects of shikonin on cell apoptosis. The influences of shikonin on cell membrane integrity were detected by lactate dehydrogenase (LDH) release assay. Reactive oxygen species (ROS) generation was analyzed using DCFH-DA as probe. The mechanisms of shikonin affecting the stability of cyclooxygenase-2 (COX-2) were evaluated by using specific inhibitors for protein degradation pathways. Western blotting was performed to assess the effects of the alteration of COX-2 expression or enzymatic activity on the related signal pathways as well as the apoptotic and pyroptotic markers.

RESULTS

Shikonin was identified as a potent cytotoxic compound against EGFR-T790M-mutant NSCLC cells. Shikonin induced cell apoptosis and pyroptosis by triggering the activation of the caspase cascade and cleavage of poly (ADP-ribose) polymerase and gasdermin E by elevating intracellular ROS levels. Further investigations revealed that shikonin induced the degradation of COX-2 via the proteasome pathway, thereby decreasing COX-2 protein level and enzymatic activity and subsequently inhibiting the downstream PDK1/Akt and Erk1/2 signaling pathways through the induction of ROS production. Notably, COX-2 overexpression attenuated shikonin-induced apoptosis and pyroptosis, whereas COX-2 inhibition with celecoxib enhanced the cytotoxic effects of shikonin.

CONCLUSIONS

Combination treatment with shikonin and COX-2 inhibitor may be a suitable therapeutic strategy for EGFR-T790M-mutant NSCLC treatment.

NRP1 overexpression potentially enhances osimertinib resistance in NSCLC via activation of the PI3K/AKT signaling pathway

Resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) is the main cause of mortality in lung cancer. This study aimed to investigate the roles of neuropilin 1 (NRP1) in non-small cell lung cancer (NSCLC). NRP1 expression was assessed in tumor tissues from patients with osimertinib-resistant (OR) NSCLC and osimertinib-responsive NSCLC as well as in patients with paracancerous NSCLC tissues who did not undergo radiotherapy or chemotherapy. In vitro experiments were conducted using five cell lines: BEAS-2B, HCC827, and PC9 cells, and the constructed OR cell lines, HCC827-OR and PC9-OR. HCC827-OR cells showing significant differences in osimertinib IC50 were selected for further study. After investigating the effects of altering NRP1 expression on cell sensitivity to osimertinib, NRP1 expression was inhibited to further investigate changes in cell viability, proliferation, migration, invasion, and apoptosis in OR cells. Additionally, bioinformatics techniques were used to detect targets (Integrin β3) and signaling pathways (PI3K/AKT) downstream of NRP1; subsequent cell experiments verified their interactivity. Finally, an orthotopic mouse tumor model was constructed using HCC827-OR cells treated with a PI3K/AKT signaling pathway activator (740Y-P), allowing exploration of the role played by the PI3K/AKT signaling pathway via NRP1 regulation on NSCLC resistance both in vivo and in vitro. Results showed that NRP1 expression was significantly increased in the cells of patients with NSCLC-OR, and increased NRP1 expression reduced HCC827 cell sensitivity to osimertinib. Both in vitro and in vivo experiments showed that NRP1 deficiency mediated by NRP1 inhibitors inhibited HCC827-OR cell proliferation, migration, and invasion, promoted tumor cell apoptosis, and enhanced osimertinib efficacy. In contrast, 740Y-P partially inhibited the effects of NRP1 inhibitors combined with osimertinib on the PI3K/AKT signaling pathway and on tumor growth in vivo and in vitro. Cellular experimental results showed that NRP1 positively regulates the Integrin β3 expression and activation of the PI3K/AKT signaling pathway. Bioinformatics analysis showed that both NRP1 and Integrin β3 may jointly participate in regulating the PI3K/AKT signaling pathway. In conclusion, our findings suggest that elevated NRP1 expression in NSCLC tumor tissues may promote NSCLC resistance to osimertinib by activating the PI3K/AKT signaling pathway, and integrin β3 potentially being involved in this process. These insights may provide a novel strategy for combination therapy for OR NSCLC.

Neratinib Efficacy in Patients With EGFR Exon 18-Mutant Non-Small-Cell Lung Cancer: Findings From the SUMMIT Basket Trial

BACKGROUND

Activating mutations in the epidermal growth factor receptor (EGFR) gene occur in 7% to 23% of patients with non-small-cell lung cancer (NSCLC). A small proportion of these (3-5%) are exon 18 mutations. Neratinib, an irreversible pan-HER tyrosine kinase inhibitor (TKI), had activity in the phase II SUMMIT basket study. We report efficacy and safety of neratinib in patients with EGFR exon 18-mutant NSCLC in SUMMIT, according to prior EGFR TKI treatment.

PATIENTS AND METHODS

Eligible patients had ECOG performance status 0-2. Prior EGFR TKIs, chemotherapy, and checkpoint inhibitors were allowed. Patients received neratinib (240 mg orally daily) and mandatory diarrhea prophylaxis with loperamide. The primary endpoint was objective response rate (ORR) at 8 weeks (ORR8); other endpoints included ORR, progression-free survival (PFS), duration of response, and safety.

RESULTS

Thirty-one patients were included (24/7 with/without prior TKI). ORR8 was 19.4% (95% CI 7.5-37.5); ORR was 32.3% (95% CI: 16.7-51.4); median PFS 5.75 months (95% CI: 2.27-9.23). Two of 7 patients with baseline central nervous system metastasis had partial responses (median PFS 3.6 months; 95% CI: 1.9-9.1). Six patients with G719A/X/C mutations had partial responses >10 months. Diarrhea was generally controlled (10% grade 3, no grade 4; one patient discontinued treatment because of diarrhea).

CONCLUSION

Neratinib had meaningful activity in selected patients with EGFR exon 18-mutant NSCLC, including patients pretreated with ≥1 TKI. Diarrhea was generally low grade. Given the lack of effective treatments after EGFR TKI failure for NSCLC with uncommon mutations, further examination of neratinib is warranted.

Almonertinib and alflutinib show novel inhibition on rare EGFR S768I mutant cells

PURPOSE

EGFR classical mutations respond well to EGFR tyrosine kinase inhibitors. However, it is uncertain whether currently available EGFR-TKIs are effective against rare EGFR mutations and compound mutations. Herein, the effectiveness of almonertinib and alflutinib, the third-generation tyrosine kinase inhibitors developed in China, on rare EGFR S768I mutations and compound mutations is identified.

METHODS

In this study, using CRISPR method, four EGFR S768I mutation cell lines were constructed, and the sensitivity of EGFR to almonertinib and alflutinib was tested, with positive controls being the 1st (gefitinib), 2nd (afatinib), and 3rd (osimertinib) generation drugs.

RESULTS

The present results indicate that almonertinib and alflutinib can effectively inhibit cell viability and proliferation in rare EGFR S768I mutations through the ERK or AKT pathways in a time-dependent manner, by blocking the cell cycle and inhibiting apoptosis.

CONCLUSIONS

These findings suggest that almonertinib and alflutinib may be potential therapeutic options for non-small cell lung cancer patients with the EGFR S768I mutation.

The molecular features of lung cancer stem cells in dedifferentiation process-driven epigenetic alterations

Cancer stem cells (CSCs) may be dedifferentiated somatic cells following oncogenic processes, representing a subpopulation of cells able to promote tumor growth with their capacities for proliferation and self-renewal, inducing lineage heterogeneity, which may be a main cause of resistance to therapies. It has been shown that the "less differentiated process" may have an impact on tumor plasticity, particularly when non-CSCs may dedifferentiate and become CSC-like. Bidirectional interconversion between CSCs and non-CSCs has been reported in other solid tumors, where the inflammatory stroma promotes cell reprogramming by enhancing Wnt signaling through nuclear factor kappa B activation in association with intracellular signaling, which may induce cells' pluripotency, the oncogenic transformation can be considered another important aspect in the acquisition of "new" development programs with oncogenic features. During cell reprogramming, mutations represent an initial step toward dedifferentiation, in which tumor cells switch from a partially or terminally differentiated stage to a less differentiated stage that is mainly manifested by re-entry into the cell cycle, acquisition of a stem cell-like phenotype, and expression of stem cell markers. This phenomenon typically shows up as a change in the form, function, and pattern of gene and protein expression, and more specifically, in CSCs. This review would highlight the main epigenetic alterations, major signaling pathways and driver mutations in which CSCs, in tumors and specifically, in lung cancer, could be involved, acting as key elements in the differentiation/dedifferentiation process. This would highlight the main molecular mechanisms which need to be considered for more tailored therapies.

Investigation through naphtho[2,3-a]pyrene on mutated EGFR mediated autophagy in NSCLC: Cellular model system unleashing therapeutic potential

Mutant epidermal growth factor receptor (EGFR) signaling has emerged as a key cause of carcinogenesis and therapy resistance in non-small cell lung cancer (NSCLC), which continues to pose a serious threat to world health. In this study, we aimed to elucidate the complex molecular pathways of EGFR-mediated autophagy signaling in NSCLC. We identified naphtho[2,3-a]pyrene, an anthraquinolone derivative, to be a promising investigational drug that targets EGFR-mediated autophagy using a cellular model system. By utilizing systems biology, we developed a computational model that explained the signaling of EGFR-mediated autophagy and identified critical crosstalk sites that could be inhibited therapeutically. As a lead compound, naphtho[2,3-a]pyrene was confirmed by molecular docking experiments. It was found to be cytotoxic to NSCLC cells, impact migration, induce apoptosis, and arrest cell cycle, both on its own and when combined with standard drugs. The anticancer efficacy of naphtho[2,3-a]pyrene was validated in vivo on CDX nude mice. It showed synergistic activity against NSCLC when coupled with gefitinib, chloroquine, and radiation. Altogether, our study highlights naphtho[2,3-a]pyrene's therapeutic promise in NSCLC by focusing on EGFR-mediated autophagy and providing a new strategy to fight drug resistance and tumor survival.

Phase III KEYNOTE-789 Study of Pemetrexed and Platinum With or Without Pembrolizumab for Tyrosine Kinase Inhibitor‒Resistant, EGFR-Mutant, Metastatic Nonsquamous Non-Small Cell Lung Cancer

PURPOSE

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are standard first-line therapy for EGFR-mutant, metastatic non-small cell lung cancer (NSCLC); however, most patients experience disease progression. We report results from the randomized, double-blind, phase III KEYNOTE-789 study of pemetrexed and platinum-based chemotherapy with or without pembrolizumab for TKI-resistant, EGFR-mutant, metastatic nonsquamous NSCLC (ClinicalTrials.gov identifier: NCT03515837).

METHODS

Adults with pathologically confirmed stage IV nonsquamous NSCLC, documented DEL19 or L858R EGFR mutation, and progression after EGFR-TKI treatment were randomly assigned 1:1 to 35 cycles of pembrolizumab 200 mg or placebo once every 3 weeks plus four cycles of pemetrexed and carboplatin or cisplatin once every 3 weeks and then maintenance pemetrexed. Dual primary end points were progression-free survival (PFS) and overall survival (OS). Final PFS testing was completed at the second interim analysis (IA2; data cutoff, December 3, 2021); OS was tested at final analysis (FA; data cutoff, January 17, 2023). Efficacy boundaries were one-sided P = .0117 for PFS and OS.

RESULTS

Four hundred ninety-two patients were randomly assigned to pembrolizumab plus chemotherapy (n = 245) or placebo plus chemotherapy (n = 247). At IA2, the median PFS was 5.6 months for pembrolizumab plus chemotherapy versus 5.5 months for placebo plus chemotherapy (hazard ratio [HR], 0.80 [95% CI, 0.65 to 0.97]; P = .0122). At FA, the median OS was 15.9 versus 14.7 months, respectively (HR, 0.84 [95% CI, 0.69 to 1.02]; P = .0362). Grade ≥3 treatment-related adverse events occurred in 43.7% of pembrolizumab plus chemotherapy recipients versus 38.6% of placebo plus chemotherapy recipients.

CONCLUSION

Addition of pembrolizumab to chemotherapy in patients with TKI-resistant, EGFR-mutant, metastatic nonsquamous NSCLC did not significantly prolong PFS or OS versus placebo plus chemotherapy in KEYNOTE-789.