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Reyes A, Muddasani R, Massarelli E. Overcoming Resistance to Checkpoint Inhibitors with Combination Strategies in the Treatment of Non-Small Cell Lung Cancer. Cancers (Basel) 2024; 16:2919. [PMID: 39199689 PMCID: PMC11353073 DOI: 10.3390/cancers16162919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/13/2024] [Accepted: 08/21/2024] [Indexed: 09/01/2024] Open
Abstract
Lung cancer continues to contribute to the highest percentage of cancer-related deaths worldwide. Advancements in the treatment of non-small cell lung cancer like immune checkpoint inhibitors have dramatically improved survival and long-term disease response, even in curative and perioperative settings. Unfortunately, resistance develops either as an initial response to treatment or more commonly as a progression after the initial response. Several modalities have been utilized to combat this. This review will focus on the various combination treatments with immune checkpoint inhibitors including the addition of chemotherapy, various immunotherapies, radiation, antibody-drug conjugates, bispecific antibodies, neoantigen vaccines, and tumor-infiltrating lymphocytes. We discuss the status of these agents when used in combination with immune checkpoint inhibitors with an emphasis on lung cancer. The early toxicity signals, tolerability, and feasibility of implementation are also reviewed. We conclude with a discussion of the next steps in treatment.
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Affiliation(s)
| | | | - Erminia Massarelli
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA 91010, USA; (A.R.); (R.M.)
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Shanshan W, Hongying M, Jingjing F, Rui Y. Metformin and buparlisib synergistically induce apoptosis of non-small lung cancer (NSCLC) cells via Akt/FoxO3a/Puma axis. Toxicol In Vitro 2024; 97:105801. [PMID: 38479708 DOI: 10.1016/j.tiv.2024.105801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 02/26/2024] [Indexed: 04/16/2024]
Abstract
Non-small cell lung cancer (NSCLC) is a global health issue lacking effective treatments. Buparlisib is a pan-PI3K inhibitor that shows promising clinical results in treating NSCLC. However, chemoresistance is inevitable and hampers the application of buparlisib. Studies show that a combination of phytochemicals and chemotherapeutics enhances its effectiveness. Here, we evaluated the role of metformin, an agent with multiple pharmacological properties, in enhancing the anti-tumour activities of buparlisib against NSCLC cells. Our results showed that metformin and buparlisib synergistically inhibited cell viability, migration, and invasion of NSCLC cells. In addition, co-treatment of metformin and buparlisib also induced cell cycle arrest and cell death in NSCLC cells. Mechanistically, metformin and buparlisib repressed Mcl-1 and upregulated Puma in NSCLC cells in a p53-independent manner. Moreover, they inhibited the PI3K/Akt signalling pathway, leading to activation of the FoxO3a/Puma signalling in NSCLC cells. Our findings suggest that combined treatment of metformin and buparlisib might provide a promising strategy for treating NSCLC.
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Affiliation(s)
- Wang Shanshan
- The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang 315020, China
| | - Ma Hongying
- The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang 315020, China
| | - Fang Jingjing
- The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang 315020, China
| | - Yu Rui
- Department of Biochemistry and Molecular Biology, and Zhejiang Key Laboratory of Pathophysiology, Medical School of Ningbo University, Ningbo, Zhejiang 315020, China.
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Yan D. Hope and Challenges: Immunotherapy in EGFR-Mutant NSCLC Patients. Biomedicines 2023; 11:2916. [PMID: 38001917 PMCID: PMC10669068 DOI: 10.3390/biomedicines11112916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
EGFR tyrosine kinase inhibitors (TKIs) are the preferred initial treatment for non-small cell lung cancer (NSCLC) patients harboring sensitive EGFR mutations. Sadly, remission is transient, and no approved effective treatment options are available for EGFR-TKI-advanced EGFR-mutant NSCLCs. Although immunotherapy with immune checkpoint inhibitors (ICIs) induces sustained cancer remission in a subset of NSCLCs, ICI therapy exhibits limited activity in most EGFR-mutant NSCLCs. Mechanistically, the strong oncogenic EGFR signaling in EGFR-mutant NSCLCs contributes to a non-inflamed tumor immune microenvironment (TIME), characterized by a limited number of CD8+ T cell infiltration, a high number of regulatory CD4+ T cells, and an increased number of inactivated infiltrated T cells. Additionally, EGFR-mutant NSCLC patients are generally non-smokers with low levels of PD-L1 expression and tumor mutation burden. Promisingly, a small population of EGFR-mutant NSCLCs still durably respond to ICI therapy. The hope of ICI therapy from pre-clinical studies and clinical trials is reviewed in EGFR-mutant NSCLCs. The challenges of application ICI therapy in EGFR-mutant NSCLCs are also reviewed.
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Affiliation(s)
- Dan Yan
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA;
- Department of Pediatrics, Emory University, Atlanta, GA 30322, USA
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Reyes A, Pharaon R, Mohanty A, Massarelli E. Arising Novel Agents in Lung Cancer: Are Bispecifics and ADCs the New Paradigm? Cancers (Basel) 2023; 15:3162. [PMID: 37370772 DOI: 10.3390/cancers15123162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Lung cancer is one of the most common cancers with the highest mortality. Non-small cell lung cancer (NSCLC) contributes to around 85% of lung cancer diagnoses (vs. 15% for small cell lung cancer). The treatment of NSCLC has vastly changed in the last two decades since the development of immunotherapy and targeted therapy against driver mutations. As is the nature of malignancy, cancer cells have acquired resistance to these treatments prompting an investigation into novel treatments and new targets. Bispecific antibodies, capable of targeting multiple substrates at once, and antibody-drug conjugates that can preferentially deliver chemotherapy to tumor cells are examples of this innovation. From our initial evaluation, both treatment modalities appear promising.
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Affiliation(s)
- Amanda Reyes
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA 910102, USA
| | - Rebecca Pharaon
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA 910102, USA
| | - Atish Mohanty
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA 910102, USA
| | - Erminia Massarelli
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA 910102, USA
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Villaruz LC, Socinski MA, Weiss J. Guidance for clinicians and patients with non-small cell lung cancer in the time of precision medicine. Front Oncol 2023; 13:1124167. [PMID: 37077826 PMCID: PMC10107372 DOI: 10.3389/fonc.2023.1124167] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
Major advances in the diagnosis and treatment of non-small cell lung cancer (NSCLC) have resulted in a sharp decline in associated mortality rates, thereby propelling NSCLC to the forefront of precision medicine. Current guidelines recommend upfront comprehensive molecular testing for all known and actionable driver alterations/biomarkers (EGFR, ALK, ROS1, BRAF, KRAS, NTRK, MET, RET, HER2 [ERBB2], and PD-L1), especially in advanced disease stages, as they significantly influence response to therapy. In particular, hybrid capture-based next-generation sequencing (HC-NGS) with an RNA fusion panel to detect gene fusions is a veritable requirement at both diagnosis and progression (resistance) of any-stage non-squamous adenocarcinoma NSCLCs. This testing modality ensures selection of the most timely, appropriate, and personalized treatment, maximization of therapeutic efficacy, and prevention of use of suboptimal/contraindicated therapy. As a complement to clinical testing and treatment, patient, family, and caregiver education is also key to early screening and diagnosis, access to care, coping strategies, positive outcomes, and survival. The advent of social media and increased internet access has amplified the volume of educational and support resources, consequently changing the dynamics of patient care. This review provides guidance on integration of comprehensive genomic testing with an RNA fusion panel as a global diagnostic standard for all adenocarcinoma NSCLC disease stages and provides key information on patient and caregiver education and resources.
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Affiliation(s)
- Liza C. Villaruz
- Hillman Cancer Center, Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- *Correspondence: Liza C. Villaruz,
| | | | - Jared Weiss
- Division of Oncology, Lineberger Comprehensive Cancer at the University of North Carolina, Chapel Hill, NC, United States
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Ding J, Ding X, Leng Z. Immunotherapy-based therapy as a promising treatment for EGFR-mutant advanced non-small cell lung cancer patients after EGFR-TKI resistance. Expert Rev Anticancer Ther 2023; 23:187-198. [PMID: 36655635 DOI: 10.1080/14737140.2023.2170879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Traditionally, epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) has been regarded as a cold tumor based on the immunosuppressive tumor immune microenvironment (TIME). However, recent studies have found that EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment could shift host immunity from immunosuppressive to immunosupportive TIME, which has renewed hopes of immunotherapy. AREAS COVERED In this review, we highlight five main immunotherapy-based therapies for patients after EGFR-TKI failure, including safety and efficacy data from prospective and retrospective clinical studies. EXPERT OPINION The efficacy of immunotherapy alone is extremely limited. Immunotherapy plus chemotherapy show an ORR of 29.5%-59.3% and an mPFS of about 7 months. There is still scarce evidence for immunotherapy plus antiangiogenesis therapy. A combination of immunotherapy with EGFR-TKIs exhibits higher treatment-related adverse events and lower clinical outcomes compared to EGFR-TKI alone. Importantly, immunotherapy plus antiangiogenesis and chemotherapy achieves an mPFS of 6.9-10.2 months. In general, the strategy of combining immunotherapy with chemotherapy and/or an antiangiogenic drug is a novel and promising method for treating advanced NSCLC after EGFR-TKI failure. Therefore, the dominant population of EGFR-TKI resistant patients were characterized by EGFR uncommon mutation, EGFR L858R mutation, PD-L1 ≥ 50%, prior antiangiogenic drugs, and negative T790 M mutation for immunotherapy-based therapy.
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Affiliation(s)
- Jianghua Ding
- Department of Hematology & Oncology, Jiujiang University Affiliated Hospital, No. 57#, Lufeng East Str., Xunyang District, 332000, Jiujiang, Jiangxi, China
| | - Xinjing Ding
- Department of Oncology, First Affiliated of Nanchang University, No. 17#, Yongwai Zheng Str., Donghu District, 330006, Nanchang, Jiangxi, China
| | - Zhaohui Leng
- Department of Hematology & Oncology, Jiujiang University Affiliated Hospital, No. 57#, Lufeng East Str., Xunyang District, 332000, Jiujiang, Jiangxi, China
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Acquired Resistance to Osimertinib in EGFR-Mutated Non-Small Cell Lung Cancer: How Do We Overcome It? Int J Mol Sci 2022; 23:ijms23136936. [PMID: 35805940 PMCID: PMC9266773 DOI: 10.3390/ijms23136936] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
Osimertinib is currently the preferred first-line therapy in patients with non-small cell lung cancer (NSCLC) with common epidermal growth factor receptor (EGFR) mutation and the standard second-line therapy in T790M-positive patients in progression to previous EGFR tyrosine kinase inhibitor. Osimertinib is a highly effective treatment that shows a high response rate and long-lasting disease control. However, a resistance to the treatment inevitably develops among patients. Understanding the secondary mechanisms of resistance and the possible therapeutic options available is crucial to define the best management of patients in progression to osimertinib. We provide a comprehensive review of the emerging molecular resistance mechanism in EGFR-mutated NSCLC pre-treated with osimertinib and its future treatment applications.
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Madeddu C, Donisi C, Liscia N, Lai E, Scartozzi M, Macciò A. EGFR-Mutated Non-Small Cell Lung Cancer and Resistance to Immunotherapy: Role of the Tumor Microenvironment. Int J Mol Sci 2022; 23:6489. [PMID: 35742933 PMCID: PMC9224267 DOI: 10.3390/ijms23126489] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 12/12/2022] Open
Abstract
Lung cancer is a leading cause of cancer-related deaths worldwide. About 10-30% of patients with non-small cell lung cancer (NSCLC) harbor mutations of the EGFR gene. The Tumor Microenvironment (TME) of patients with NSCLC harboring EGFR mutations displays peculiar characteristics and may modulate the antitumor immune response. EGFR activation increases PD-L1 expression in tumor cells, inducing T cell apoptosis and immune escape. EGFR-Tyrosine Kinase Inhibitors (TKIs) strengthen MHC class I and II antigen presentation in response to IFN-γ, boost CD8+ T-cells levels and DCs, eliminate FOXP3+ Tregs, inhibit macrophage polarization into the M2 phenotype, and decrease PD-L1 expression in cancer cells. Thus, targeted therapy blocks specific signaling pathways, whereas immunotherapy stimulates the immune system to attack tumor cells evading immune surveillance. A combination of TKIs and immunotherapy may have suboptimal synergistic effects. However, data are controversial because activated EGFR signaling allows NSCLC cells to use multiple strategies to create an immunosuppressive TME, including recruitment of Tumor-Associated Macrophages and Tregs and the production of inhibitory cytokines and metabolites. Therefore, these mechanisms should be characterized and targeted by a combined pharmacological approach that also concerns disease stage, cancer-related inflammation with related systemic symptoms, and the general status of the patients to overcome the single-drug resistance development.
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Affiliation(s)
- Clelia Madeddu
- Department of Medical Sciences and Public Health, Medical Oncology Unit, “Azienda Ospedaliero Universitaria” of Cagliari, University of Cagliari, 09100 Cagliari, Italy; (C.M.); (N.L.); (E.L.); (M.S.)
| | - Clelia Donisi
- Department of Medical Sciences and Public Health, Medical Oncology Unit, “Azienda Ospedaliero Universitaria” of Cagliari, University of Cagliari, 09100 Cagliari, Italy; (C.M.); (N.L.); (E.L.); (M.S.)
| | - Nicole Liscia
- Department of Medical Sciences and Public Health, Medical Oncology Unit, “Azienda Ospedaliero Universitaria” of Cagliari, University of Cagliari, 09100 Cagliari, Italy; (C.M.); (N.L.); (E.L.); (M.S.)
| | - Eleonora Lai
- Department of Medical Sciences and Public Health, Medical Oncology Unit, “Azienda Ospedaliero Universitaria” of Cagliari, University of Cagliari, 09100 Cagliari, Italy; (C.M.); (N.L.); (E.L.); (M.S.)
| | - Mario Scartozzi
- Department of Medical Sciences and Public Health, Medical Oncology Unit, “Azienda Ospedaliero Universitaria” of Cagliari, University of Cagliari, 09100 Cagliari, Italy; (C.M.); (N.L.); (E.L.); (M.S.)
| | - Antonio Macciò
- Gynecologic Oncology Unit, ARNAS G. Brotzu, Department of Surgical Sciences, University of Cagliari, 09100 Cagliari, Italy;
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