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Sai-Hong Ignatius Ou,1 Xiuning Le,2 Misako Nagasaka,1 Thanyanan Reungwetwattana,3 Myung-Ju Ahn,4 Darren WT Lim,5 Edgardo S Santos,6 Elaine Shum,7 Sally CM Lau,7 Jii Bum Lee,8 Antonio Calles,9 Fengying Wu,10 Gilberto Lopes,11 Virote Sriuranpong,12 Junko Tanizaki,13 Hidehito Horinouchi,14 Marina C Garassino,15 Sanjay Popat,16 Benjamin Besse,17 Rafael Rosell,18 Ross A Soo19 1University of California Irvine School of Medicine, Chao Family Comprehensive Cancer Center, Orange, CA, USA; 2University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 4Department of Hematology and Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 5Duke-NUS School of medicine, National Cancer Center Singapore, Republic of Singapore; 6Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA; 7NYU Langone Perlmutter Cancer Center, NY, NY, USA; 8Yonsei Cancer Center Yonsei University, Seoul, Republic of Korea; 9Department of Medicine, Division of Medical Oncology, Early Drug Development and Phase I Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain; 10Shanghai Chest hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China; 11Department of Medicine, Division of Medical Oncology, Sylvester Comprehensive Cancer Center at the University of Miami and the Miller School of Medicine, Miami, FL, 33136, USA; 12Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 13Department of Medicine, Kindai University School of Medicine, Osaka, Japan; 14Department of Thoracic Oncology, National Cancer Center Hospital Tokyo, Tokyo, Japan; 15Department of Medicine, Division of Medical Oncology-Hematology, University of Chicago Medicine, Chicago, IL, USA; 16Royal Marsden Hospital, London, Imperial College, London, UK; 17Gustave Roussy Cancer Campus, Villejuif, France; Paris-Saclay University, Orsay, France; 18Department of Hematology-Oncology, National University Cancer Institute, National University Hospital Singapore, Republic of Singapore; 19IOR, Quirón-Dexeus University Institute; ICO, Catalan Institute of Oncology; IGTP, Germans Trias i Pujol Research Institute, Barcelona, SpainCorrespondence: Sai-Hong Ignatius Ou, University of California School of Medicine, Department of Medicine, Division of Hematology-Oncology, Chao Family Comprehensive Cancer Center, 200 South Manchester Avenue, Suite 400, Orange, CA, 92868, USA, Tel +1 714-456-5153, Fax +1 714-456-2242, Email Siou@hs.uci.eduAbstract: The year 2024 is the 20th anniversary of the discovery of activating epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC). Since then, tremendous advances have been made in the treatment of NSCLC based on this discovery. Some of these studies have led to seismic changes in the concept of oncology research and spurred treatment advances beyond NSCLC, leading to a current true era of precision oncology for all solid tumors. We now routinely molecularly profile all tumor types and even plasma samples of patients with NSCLC for multiple actionable driver mutations, independent of patient clinical characteristics nor is profiling limited to the advanced incurable stage. We are increasingly monitoring treatment responses and detecting resistance to targeted therapy by using plasma genotyping. Furthermore, we are now profiling early-stage NSCLC for appropriate adjuvant targeted treatment leading to an eventual potential “cure” in early-stage EGFR+ NSCLC which have societal implication on implementing lung cancer screening in never-smokers as most EGFR+ NSCLC patients are never-smokers. All these advances were unfathomable in 2004 when the five papers that described “discoveries” of activating EGFR mutations (del19, L858R, exon 20 insertions, and “uncommon” mutations) were published. To commemorate this 20th anniversary, we assembled a global panel of thoracic medical oncology experts to select the top 20 papers (publications or congress presentation) from the 20 years since this seminal discovery with December 31, 2023 as the cutoff date for inclusion of papers to be voted on. Papers ranked 21 to 30 were considered “honorable mention” and also annotated. Our objective is that these 30 papers with their annotations about their impact and even all the ranked papers will serve as “syllabus” for the education of future thoracic oncology trainees. Finally, we mentioned potential practice-changing clinical trials to be reported. One of them, LAURA was published online on June 2, 2024 was not included in the list of papers to be voted on but will surely be highly ranked if this consensus survery is performed again on the 25th anniversay of the discovery EGFR mutations (i.e. top 25 papers on the 25 years since the discovery of activating EGFR mutations).Keywords: EGFR mutations, expert panel, top 20 papers, 20th anniversary, NSCLC

Background: Osimertinib is a recommended treatment for advanced non-small-cell lung cancer (NSCLC) with an epidermal growth factor receptor ( EGFR ) mutation and as adjuvant treatment for resected EGFR -mutated NSCLC. EGFR tyrosine kinase inhibitors have shown preliminary efficacy in unresectable stage III EGFR -mutated NSCLC., Methods: In this phase 3, double-blind, placebo-controlled trial, we randomly assigned patients with unresectable EGFR -mutated stage III NSCLC without progression during or after chemoradiotherapy to receive osimertinib or placebo until disease progression occurred (as assessed by blinded independent central review) or the regimen was discontinued. The primary end point was progression-free survival as assessed by blinded independent central review., Results: A total of 216 patients who had undergone chemoradiotherapy were randomly assigned to receive osimertinib (143 patients) or placebo (73 patients). Osimertinib resulted in a significant progression-free survival benefit as compared with placebo: the median progression-free survival was 39.1 months with osimertinib versus 5.6 months with placebo, with a hazard ratio for disease progression or death of 0.16 (95% confidence interval [CI], 0.10 to 0.24; P<0.001). The percentage of patients who were alive and progression free at 12 months was 74% (95% CI, 65 to 80) with osimertinib and 22% (95% CI, 13 to 32) with placebo. Interim overall survival data (maturity, 20%) showed 36-month overall survival among 84% of patients with osimertinib (95% CI, 75 to 89) and 74% with placebo (95% CI, 57 to 85), with a hazard ratio for death of 0.81 (95% CI, 0.42 to 1.56; P = 0.53). The incidence of adverse events of grade 3 or higher was 35% in the osimertinib group and 12% in the placebo group; radiation pneumonitis (majority grade, 1 to 2) was reported in 48% and 38%, respectively. No new safety concerns emerged., Conclusions: Treatment with osimertinib resulted in significantly longer progression-free survival than placebo in patients with unresectable stage III EGFR -mutated NSCLC. (Funded by AstraZeneca; LAURA ClinicalTrials.gov number, NCT03521154.)., (Copyright © 2024 Massachusetts Medical Society.)

Preclinical studies suggest that loss of LKB1 expression renders cancer cells less responsive to radiation partly through NRF2-mediated upregulation of antioxidant enzymes protecting against radiation-induced DNA damage. Here we investigated the association of an alteration in this pathway with radio-resistance in lung cancer patients. Patients with locally advanced non-small cell lung cancer (LA-NSCLC) who were treated with chemoradiotherapy (CRT) and analyzed for LKB1 expression using semiquantitative immunohistochemistry. Clinical characteristics and expression of LKB1 were analyzed for association with radiotherapy outcomes. We analyzed 74 available tumor specimens from 178 patients. After a median follow-up of 40.7 months, 2-year cumulative incidence of locoregional recurrence (LRR) in patients who had LKB1 Low expression was significantly higher than those with LKB1 High expression (68.8% vs. 31.3%, P = 0.0001). LKB1 Low expression was found significantly associated with a higher incidence of distant metastases (DM) (P = 0.0008), shorter disease-free survival (DFS) (P = 0.006), and worse overall survival (OS) (P = 0.02) compared to LKB1 High expression. Moreover, patients with LKB1 Low expression showed a significantly higher 2-year cumulative incidence of LRR (77.6% vs. 21%; P = 0.02), higher DM recurrence (P = 0.002), and shorter OS (P < 0.0001) compared with the EGFR-mutant group. For all patients with LKB1 Low who had LRR, these recurrences occurred within the field of radiation, in contrast to those with LKB1 High expression having both in-field, marginal, and out-of-field failures. LKB1 expression may serve as a potential biomarker for poor outcomes after receiving radiation in LA-NSCLC patients. Further studies to confirm the association and application are warranted., (© 2024. The Author(s).)