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Tissue inhibitor of metalloproteinase-1 (TIMP-1) is an important regulator of extracellular matrix turnover that has been traditionally regarded as a potential tumor suppressor owing to its inhibitory effects of matrix metalloproteinases. Intriguingly, this interpretation has been challenged by the consistent observation that increased expression of TIMP-1 is associated with poor prognosis in virtually all cancer types including lung cancer, supporting a tumor-promoting function. However, how TIMP-1 is dysregulated within the tumor microenvironment and how it drives tumor progression in lung cancer is poorly understood. We analyzed the expression of TIMP-1 and its cell surface receptor CD63 in two major lung cancer subtypes: lung adenocarcinoma (ADC) and squamous cell carcinoma (SCC), and defined the tumor-promoting effects of their interaction. We found that TIMP-1 is aberrantly overexpressed in tumor-associated fibroblasts (TAFs) in ADC compared to SCC. Mechanistically, TIMP-1 overexpression was mediated by the selective hyperactivity of the pro-fibrotic TGF-β1/SMAD3 pathway in ADC-TAFs. Likewise, CD63 was upregulated in ADC compared to SCC cells. Genetic analyses revealed that TIMP-1 secreted by TGF-β1-activated ADC-TAFs is both necessary and sufficient to enhance growth and invasion of ADC cancer cells in culture, and that tumor cell expression of CD63 was required for these effects. Consistently, in vivo analyses revealed that ADC cells co-injected with fibroblasts with reduced SMAD3 or TIMP-1 expression into immunocompromised mice attenuated tumor aggressiveness compared to tumors bearing parental fibroblasts. We also found that high TIMP1 and CD63 mRNA levels combined define a stronger prognostic biomarker than TIMP1 alone. Our results identify an excessive stromal TIMP-1 within the tumor microenvironment selectively in lung ADC, and implicate it in a novel tumor-promoting TAF-carcinoma crosstalk, thereby pointing to TIMP-1/CD63 interaction as a novel therapeutic target in lung cancer.

Dataset of 65 tumor samples.

Expression of the 23 genes and signatures across the 3 cancer groups in the nCounter-based dataset

Antibody targeting of the immune checkpoint receptor PD1 produces therapeutic activity in a variety of solid tumors, but most patients exhibit partial or complete resistance to treatment for reasons that are unclear. In this study, we evaluated tumor specimens from 65 patients with melanoma, lung nonsquamous, squamous cell lung or head and neck cancers who were treated with the approved PD1-targeting antibodies pembrolizumab or nivolumab. Tumor RNA before anti-PD1 therapy was analyzed on the nCounter system using the PanCancer 730-Immune Panel, and we identified 23 immune-related genes or signatures linked to response and progression-free survival (PFS). In addition, we evaluated intra- and interbiopsy variability of PD1, PD-L1, CD8A, and CD4 mRNAs and their relationship with tumor-infiltrating lymphocytes (TIL) and PD-L1 IHC expression. Among the biomarkers examined, PD1 gene expression along with 12 signatures tracking CD8 and CD4 T-cell activation, natural killer cells, and IFN activation associated significantly with nonprogressive disease and PFS. These associations were independent of sample timing, drug used, or cancer type. TIL correlated moderately (∼0.50) with PD1 and CD8A mRNA levels and weakly (∼0.35) with CD4 and PD-L1. IHC expression of PD-L1 correlated strongly with PD-L1 (0.90), moderately with CD4 and CD8A, and weakly with PD1. Reproducibility of gene expression in intra- and interbiopsy specimens was very high (total SD Cancer Res; 77(13); 3540–50. ©2017 AACR.

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Supplementary Figures S1-S7

Supplementary Material

The tumor-promoting fibrotic stroma rich in tumor-associated fibroblasts (TAF) is drawing increased therapeutic attention. Intriguingly, a trial with the antifibrotic drug nintedanib in non–small cell lung cancer reported clinical benefits in adenocarcinoma (ADC) but not squamous cell carcinoma (SCC), even though the stroma is fibrotic in both histotypes. Likewise, we reported that nintedanib inhibited the tumor-promoting fibrotic phenotype of TAFs selectively in ADC. Here we show that tumor fibrosis is actually higher in ADC-TAFs than SCC-TAFs in vitro and patient samples. Mechanistically, the reduced fibrosis and nintedanib response of SCC-TAFs was associated with increased promoter methylation of the profibrotic TGFβ transcription factor SMAD3 compared with ADC-TAFs, which elicited a compensatory increase in TGFβ1/SMAD2 activation. Consistently, forcing global DNA demethylation of SCC-TAFs with 5-AZA rescued TGFβ1/SMAD3 activation, whereas genetic downregulation of SMAD3 in ADC-TAFs and control fibroblasts increased TGFβ1/SMAD2 activation, and reduced their fibrotic phenotype and antitumor responses to nintedanib in vitro and in vivo. Our results also support that smoking and/or the anatomic location of SCC in the proximal airways, which are more exposed to cigarette smoke particles, may prime SCC-TAFs to stronger SMAD3 epigenetic repression, because cigarette smoke condensate selectively increased SMAD3 promoter methylation. Our results unveil that the histotype-specific regulation of tumor fibrosis in lung cancer is mediated through differential SMAD3 promoter methylation in TAFs and provide new mechanistic insights on the selective poor response of SCC-TAFs to nintedanib. Moreover, our findings support that patients with ADC may be more responsive to antifibrotic drugs targeting their stromal TGFβ1/SMAD3 activation.Significance:This study implicates the selective epigenetic repression of SMAD3 in SCC-TAFs in the clinical failure of nintedanib in SCC and supports that patients with ADC may benefit from antifibrotic drugs targeting stromal TGFβ1/SMAD3.

No abstract available

Defining the optimal neoadjuvant strategy in early-stage and locoregional (N2) oncogenic-driven lung cancer remains a major challenge for the scientific community. Whereas significant advances have been achieved with the use of personalized medicine and targeted therapies in advanced stages, we are still far from translating the same magnitude of benefits into an earlier-stage disease. Perioperative strategies with neoadjuvant and adjuvant tyrosine kinase inhibitors in patients with EGFR and ALK gene alterations have yielded mixed results and further biomarker-driven trials are needed to shed more light on the significance of inhibiting the oncogenic signaling addiction at earlier stages of the disease and the conceivable value of incorporating more potent targeted inhibitors in this setting. Meanwhile, the landscape of early-stage lung cancer management is progressing rapidly, and we anticipate the incorporation of novel immunotherapeutic agents on the basis of this promising preliminary activity as induction strategies. Whether the benefits observed in the overall population can be translated into specific subsets of oncogenic-driven tumors is still unknown, but it clearly reinforces the importance of incorporating-sooner rather than later-a biomarker-testing strategy into the routine work-up of early-stage non-small cell lung cancer (NSCLC). There are still many challenges to overcome such as the need to stablish standardized surrogate endpoints and to define the optimal duration of perioperative treatment, as well as how to expedite patient recruitment using enrichment strategies for biomarker stratified trials. Despite the difficulties, we are living in exciting times and coming up on a new window of opportunities for achieving the ultimate goal of curing early-stage lung cancer and improving long-term outcomes by eliminating the minimal residual disease and reducing the risk for metastatic recurrence.

Purpose Osimertinib has proven efficacy in EGFR T790M mutation-positive non-small cell lung cancer (NSCLC) patients; however, its benefits have not been evaluated in a real-world setting. Methods ASTRIS is a single-arm, open-label, multinational study to evaluate the efficacy and safety of osimertinib for the treatment of EGFR T790M mutation-positive NSCLC. We present the study design and preliminary cut-off analysis results (as of October 2017) describing the baseline characteristics and methodology for T790M mutation detection in the Spanish cohort. Results The Spanish cohort included 131 patients from a total 3014 patients. Forty patients (28.1%) were still undergoing therapy at the time of cut-off; 68.7% were women and 97.7% were Caucasian, with a mean age of 64.8 (SD 11.7) years. The most common type of sample for evaluating T790M mutations was tissue (55.0%), and samples were obtained from the primary tumor in 61.1% of cases. Mutation analysis was performed by the local laboratory in 60.3% of cases and using the Roche Cobas® EGFR assay in 43.5% of cases. Conclusions ASTRIS is expected to confirm the benefits of osimertinib in a real-world setting. Data on real-world practices for the detection of the EGFR T790M mutation may provide additional information for the designing of guidelines for best practices.

Adenocarcinoma (ADC) and Squamous Cell Carcinoma (SCC) are the most frequent histologic subtypes of lung cancer, and both are rich in activated/myofibroblast-like tumor-associated fibroblasts (TAFs). Nintedanib is a potent antifibrotic drug that targets the tumor stroma and is clinically approved to treat advanced lung ADC patients owing to the survival benefits observed in the LUME-1 clinical trial in ADC but not SCC patients. Although the mechanism underlying the ADC-selective therapeutic effects of nintedanib remained poorly understood, we have previously reported that nintedanib abrogates the pro-tumoral traits of the secretome of ADC-TAFs but not SCC-TAFs, suggesting that secreted factor(s) in ADC-TAFs may be implicated. In addition, we recently unveiled an ADC-specific tumor-promoting crosstalk between TAFs and cancer cells driven by TIMP-1 and CD63, whereas others have shown that TIMP-1 is a molecular target of nintedanib. However, it remains unknown if TIMP-1 is involved in the ADC-selective benefits of nintedanib. To address this question, we used patient-derived TAFs obtained with the patient’s informed consent and using protocols approved by the Ethics Committee of the Hospital Clinic. We treated TGF-β1-activated ADC-TAFs and SCC-TAFs with nintedanib and determined the content of TIMP-1 in their conditioned medium by ELISA. Moreover, we used cell-based functional assays and tumor xenografts after knocking-down TIMP-1 in TAFs by siRNA to examine how silencing TIMP-1 altered their response to nintedanib. By analyzing TCGA data and the human protein atlas, we found that TIMP-1 is consistently upregulated in ADC compared to SCC tumors both at the mRNA and protein levels. Moreover, TCGA data revealed that TIMP-1 is increased in tumors compared to paired control tissue in ADC but not SCC. In culture, we observed that TIMP-1 secretion was higher in ADC-TAFs than SCC-TAFs, and that this secretion was downregulated by nintedanib to a larger extent in ADC-TAFs compared to SCC-TAFs. In vivo analyses revealed that ADC cells co-injected with fibroblasts silenced for TIMP-1 as in SCC-TAFs into immunocompromised mice exhibited a less invasive growth pattern compared to tumors bearing control fibroblasts. In addition, we observed that the inhibition of the pro-tumoral secretome of ADC-TAFs elicited by nintedanib was abrogated upon knocking-down TIMP-1 in TAFs both in vitro and in vivo. Collectively, these results reveal that the high secretion of TIMP-1 in ADC-TAFs render them more responsive to nintedanib, whereas the low TIMP-1 secretion of SCC-TAFs may be a major contributor to the selective resistance of SCC patients to nintedanib. Moreover, our results identify TIMP-1 as a promising predictive biomarker of nintedanib responses. Citation Format: Paula Duch, Natalia Díaz-Valdivia, Marta Gabasa, Rafael Ikemori, Frank Hilberg, Noemí Reguart, Derek Radisky, Jordi Alcaraz. Aberrant TIMP-1 secretion by tumor-associated fibroblasts is a major contributor to the selective positive response to nintedanib in lung adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2356.

Background The TGF-β1 transcription factor SMAD3 is epigenetically repressed in tumour-associated fibroblasts (TAFs) from lung squamous cell carcinoma (SCC) but not adenocarcinoma (ADC) patients, which elicits a compensatory increase in SMAD2 that renders SCC-TAFs less fibrotic. Here we examined the effects of altered SMAD2/3 in fibroblast migration and its impact on the desmoplastic stroma formation in lung cancer. Methods We used a microfluidic device to examine descriptors of early protrusions and subsequent migration in 3D collagen gels upon knocking down SMAD2 or SMAD3 by shRNA in control fibroblasts and TAFs. Results High SMAD3 conditions as in shSMAD2 fibroblasts and ADC-TAFs exhibited a migratory advantage in terms of protrusions (fewer and longer) and migration (faster and more directional) selectively without TGF-β1 along with Erk1/2 hyperactivation. This enhanced migration was abrogated by TGF-β1 as well as low glucose medium and the MEK inhibitor Trametinib. In contrast, high SMAD2 fibroblasts were poorly responsive to TGF-β1, high glucose and Trametinib, exhibiting impaired migration in all conditions. Conclusions The basal migration advantage of high SMAD3 fibroblasts provides a straightforward mechanism underlying the larger accumulation of TAFs previously reported in ADC compared to SCC. Moreover, our results encourage using MEK inhibitors in ADC-TAFs but not SCC-TAFs.

The tumor-promoting fibrotic stroma rich in tumor-associated fibroblasts (TAF) is drawing increased therapeutic attention. Intriguingly, a trial with the antifibrotic drug nintedanib in non–small cell lung cancer reported clinical benefits in adenocarcinoma (ADC) but not squamous cell carcinoma (SCC), even though the stroma is fibrotic in both histotypes. Likewise, we reported that nintedanib inhibited the tumor-promoting fibrotic phenotype of TAFs selectively in ADC. Here we show that tumor fibrosis is actually higher in ADC-TAFs than SCC-TAFs in vitro and patient samples. Mechanistically, the reduced fibrosis and nintedanib response of SCC-TAFs was associated with increased promoter methylation of the profibrotic TGFβ transcription factor SMAD3 compared with ADC-TAFs, which elicited a compensatory increase in TGFβ1/SMAD2 activation. Consistently, forcing global DNA demethylation of SCC-TAFs with 5-AZA rescued TGFβ1/SMAD3 activation, whereas genetic downregulation of SMAD3 in ADC-TAFs and control fibroblasts increased TGFβ1/SMAD2 activation, and reduced their fibrotic phenotype and antitumor responses to nintedanib in vitro and in vivo. Our results also support that smoking and/or the anatomic location of SCC in the proximal airways, which are more exposed to cigarette smoke particles, may prime SCC-TAFs to stronger SMAD3 epigenetic repression, because cigarette smoke condensate selectively increased SMAD3 promoter methylation. Our results unveil that the histotype-specific regulation of tumor fibrosis in lung cancer is mediated through differential SMAD3 promoter methylation in TAFs and provide new mechanistic insights on the selective poor response of SCC-TAFs to nintedanib. Moreover, our findings support that patients with ADC may be more responsive to antifibrotic drugs targeting their stromal TGFβ1/SMAD3 activation. Significance: This study implicates the selective epigenetic repression of SMAD3 in SCC-TAFs in the clinical failure of nintedanib in SCC and supports that patients with ADC may benefit from antifibrotic drugs targeting stromal TGFβ1/SMAD3.

Propósito: realizar una revisión de la evidencia acerca del tratamiento del cáncer de pulmón de célula no pequeña (CPCNP). Fuente de los datos: la información se obtuvo a partir de búsquedas practicadas en MEDLINE, CCT R, BIOSIS , EMBASE , LIL ACS y CIN HAL. También se recopilaron las referencias más representativas presentadas durante los últimos cinco años en los congresos ASCO, ESMO y de la IASLC. Extracción de los datos: los datos fueron extraídos por miembros asociados al ONCOLGroup. La recopilación de la información no siguió una estrategia uniforme. Resultados de la síntesis de datos: la terapia que se utiliza para tratar el carcinoma de pulmón de células no pequeñas (CPCNP) mejora la supervivencia global y la calidad de vida; no obstante, la mayoría de los pacientes mueren por la enfermedad antes del segundo año del diagnóstico, evento que ha favorecido la generación de nuevas estrategias que permitirán optimizar este desenlace. En la actualidad, el tratamiento estándar de primera línea implica varias combinaciones con base en algún platino que incrementan la supervivencia en comparación con la monoterapia y el mejor soporte paliativo. Estos regímenes son comparables respecto de su eficacia, pero difieren en el perfil de seguridad. Nuevas alternativas de tratamiento dirigidas contra blancos moleculares benefician a poblaciones específicas, cuando se administran solas o con otros agentes con los que presentan sinergismo. Esta revisión no realizó una evaluación sistemática de la evidencia. Conclusión: la terapia médica utilizada en el CPCNP modifica positivamente los desenlaces principales, incluyendo la calidad de vida

Simple Summary Lung cancer is the leading cause of cancer death among both men and women, partly due to limited therapy responses. New avenues of knowledge are indicating that lung cancer cells do not form a tumor in isolation but rather obtain essential support from their surrounding host tissue rich in altered fibroblasts. Notably, there is growing evidence that tumor progression and even the current limited responses to therapies could be prevented by rescuing the normal behavior of fibroblasts, which are critical housekeepers of normal tissue function. For this purpose, it is key to improve our understanding of the molecular mechanisms driving the pathologic alterations of fibroblasts in cancer. This work provides a comprehensive review of the main molecular mechanisms involved in fibroblast transformation based on epigenetic reprogramming, and summarizes emerging therapeutic approaches to prevent or overcome the pathologic effects of tumor-associated fibroblasts. Abstract Lung cancer is the leading cause of cancer-related death worldwide. The desmoplastic stroma of lung cancer and other solid tumors is rich in tumor-associated fibroblasts (TAFs) exhibiting an activated/myofibroblast-like phenotype. There is growing awareness that TAFs support key steps of tumor progression and are epigenetically reprogrammed compared to healthy fibroblasts. Although the mechanisms underlying such epigenetic reprogramming are incompletely understood, there is increasing evidence that they involve interactions with either cancer cells, pro-fibrotic cytokines such as TGF-β, the stiffening of the surrounding extracellular matrix, smoking cigarette particles and other environmental cues. These aberrant interactions elicit a global DNA hypomethylation and a selective transcriptional repression through hypermethylation of the TGF-β transcription factor SMAD3 in lung TAFs. Likewise, similar DNA methylation changes have been reported in TAFs from other cancer types, as well as histone core modifications and altered microRNA expression. In this review we summarize the evidence of the epigenetic reprogramming of TAFs, how this reprogramming contributes to the acquisition and maintenance of a tumor-promoting phenotype, and how it provides novel venues for therapeutic intervention, with a special focus on lung TAFs.

Purpose/Objective(s) Pembrolizumab, an anti‒PD-1 antibody is standard of care therapy for metastatic non‒small-cell lung cancer (NSCLC) as monotherapy and in combination with chemotherapy. Durvalumab, an anti–PD-L1 antibody, is approved for unresectable, stage III NSCLC without disease progression following CCRT. Early trials of pembrolizumab in combination with chemoradiotherapy, either concurrently or as consolidation, showed acceptable tolerability and promising PFS in patients with unresectable stage III NSCLC. Early data suggest the combination of poly(ADP-ribose) polymerase (PARP) plus anti–PD-(L)1 inhibition can enhance treatment effects. KEYLYNK-012 (NCT04380636) is evaluating pembrolizumab plus CCRT followed by pembrolizumab with/without the PARP inhibitor olaparib vs CCRT followed by durvalumab in patients with unresectable, locally advanced, stage III NSCLC. Materials/Methods This global phase 3, randomized, placebo- and active-controlled, double-blind study is enrolling patients aged ≥18 y with previously untreated, pathologically confirmed, stage IIIA–C NSCLC, an ECOG PS of 0 or 1, and a tumor sample available for PD-L1 evaluation. Patients are randomized 1:1:1 to CCRT (platinum-doublet chemotherapy [cisplatin plus pemetrexed or etoposide; or carboplatin plus paclitaxel] plus radiotherapy 60 Gy over 6 wks [cycles 2–3]) with pembrolizumab 200 mg Q3W (groups A and B) or CCRT alone (group C) for 3 cycles. This is followed by pembrolizumab 200 mg Q3W for 17 cycles plus placebo (group A) or olaparib 300 mg BID (group B); or durvalumab 10 mg/kg Q2W for 26 cycles (group C). Randomization is stratified by disease stage (IIIA vs IIIB/IIIC), tumor histology (squamous vs nonsquamous), PD-L1 tumor proportion score (≥50% vs Results forthcoming Conclusion forthcoming

Purpose/Objective(s) KEYNOTE-799 (NCT03631784), a phase 2 study of the anti‒PD-1 antibody pembrolizumab (pembro) plus concurrent chemoradiation therapy (cCRT) in patients (pts) with unresectable, locally advanced stage III NSCLC, completed accrual and follow up is ongoing. Results in a subset of pts from this study showed an ORR of 69.6% in cohort A (squamous [sq]/nonsquamous [nonsq], n = 112) and 70.5% in cohort B (nonsq, n = 61), and grade ≥3 pneumonitis in 8.0% and 7.9% of pts, respectively. We assessed safety and efficacy of pembro + cCRT in all pts from KEYNOTE-799. Materials/Methods This nonrandomized, multisite, open-label trial enrolled pts aged ≥18 y with previously untreated, unresectable, pathologically confirmed, stage IIIA‒C NSCLC with measurable disease per RECIST v1.1. Pts in cohort A (sq and nonsq) received 1 cycle of carboplatin AUC 6 and paclitaxel 200 mg/m2 and pembro 200 mg. After 3 weeks, pts received carboplatin AUC 2 and paclitaxel 45 mg/m2 QW for 6 weeks and 2 cycles of pembro 200 mg Q3W + standard thoracic radiotherapy (TRT; using a standardized 3D conformal radiotherapy technique on a linear accelerator operating at ≥6 MV beam energy for a total target dose of 60 Gy in 30 daily fractions of 2 Gy). Pts in cohort B (nonsq) received 3 cycles of cisplatin 75 mg/m2, pemetrexed 500 mg/m2, and pembro 200 mg Q3W, and TRT in cycles 2 and 3. All pts received up to 14 additional cycles of pembro 200 mg Q3W. Primary endpoints were ORR per RECIST v1.1 by BICR and incidence of grade ≥3 pneumonitis (per NCI CTCAE v4.0); assessed in all pts as-treated. Results Of 216 pts enrolled (cohort A, n = 112; cohort B, n = 104), 112 in cohort A and 102 in cohort B were treated. As of October 28, 2020, the median (range) time from first dose to database cutoff was 18.5 (13.6–23.8) months in cohort A and 13.7 (2.9–23.5) months in cohort B. ORR (95% CI) was 70.5% (61.2%‒78.8%) and 70.6% (60.7%‒79.2%), respectively. Median DOR, OS, and PFS were not reached in either cohort. Twelve-month OS and PFS rates were 81.3% and 67.1% in cohort A; and 87.0% and 71.6% in cohort B. Grade ≥3 pneumonitis occurred in 9 pts (8.0%) in cohort A and 7 (6.9%) in cohort B. Median (range) time to onset of any pneumonitis was 4.3 (1.4–10.4) months in cohort A, and 4.4 (0.1–12.3) months in cohort B. Grade 3–5 treatment-related AEs occurring in ≥10% pts were neutropenia (cohort A, 16.1%; cohort B, 9.8%) and anemia (10.7% and 4.9%). See Table for additional safety data. Conclusion Pembro + cCRT continues to demonstrate promising antitumor activity, and manageable toxicity in pts with previously untreated, locally advanced, stage III NSCLC with longer follow-up.

Simple Summary The use of targeted drugs has brought about the development of new imaging techniques which are able to assess in vivo processes and changes in vascularization parameters can be captured as part of the antitumor response to antiangiogenic therapies. This pilot study (IMPACT trial, NCT02316327) aimed to explore the capacity of Perfusion-Computed Tomography (pCT) to detect early changes in tumor vascularization in non-small cell lung cancer (NSCLC) patients treated with an antiangiogenic-based therapy. Our results confirm the feasibility of pCT to capture early changes in tumor vasculature and suggest the potential of blood volume (BV) to early identify differential tumor responses to antiangiogenic therapy. Abstract Background: The role of perfusion computed tomography (pCT) in detecting changes in tumor vascularization as part of a response to antiangiogenic therapy in non-small cell lung cancer (NSCLC) remains unclear. Methods: In this prospective pilot study (IMPACT trial, NCT02316327), we aimed to determine the ability of pCT to detect early changes in blood flow (BF), blood volume (BV), and permeability (PMB), and to explore whether these changes could predict the response at day +42 in patients with advanced, treatment-naive, non-squamous NSCLC treated with cisplatin and gemcitabine plus bevacizumab. Results: All of the perfusion parameters showed a consistent decrease during the course of treatment. The BV difference between baseline and early assessment was significant (p = 0.013), whereas all perfusion parameters showed significant differences between baseline and day +42 (p = 0.003, p = 0.049, and p = 0.002, respectively). Among the 16 patients evaluable for efficacy, a significant decline in BV at day +7 from baseline was observed in tumors with no response (p = 0.0418). Conclusions: Our results confirm that pCT can capture early changes in tumor vasculature. A substantial early decline of BV from baseline might identify tumors less likely responsive to antiangiogenic-drugs.

The aim of our study was to investigate the correlation between cfDNA concentration and fragment size fraction with FDG PET/CT- and CT-derived parameters in untreated NSCLC patient. Fifty-three patients diagnosed of locally advanced or metastatic NSCLC who had undergone FDG PET/CT, CT and cfDNA analysis prior to any treatment were included in this retrospective study. CfDNA concentration was measured by fluorometry and fragment size fractions were determined by microchip electrophoresis. [18F]F-FDG PET/CT was performed and standardised uptake values (SUV), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) were calculated for primary, extrapulmonary and total disease. CT scans were evaluated according to RECIST 1.1 criteria. CfDNA concentration showed a positive correlation with extrapulmonary MTV (r2 = 0.36, P = 0.009), and extrapulmonary TLG (r2 = 0.35, P = 0.009) and their whole-body (wb) ratios. Higher concentrations of total cfDNA were found in patients with liver lesions. Short fragments of cfDNA (100–250 bp) showed a positive correlation with extrapulmonary MTV (r2 = 0.49, P = 0.0005) and extrapulmonary TLG (r2 = 0.39, P = 0.006) and their respective wb ratios, and a negative correlation with SUVmean (r2 = −0.31, P = 0.03) and SUVmean/SUVmax ratio (r2 = −0.34, P = 0.02). A higher fraction of short cfDNA fragments was found in patients with liver and pleural lesions. This study supports the hypothesis that cfDNA concentration and short cfDNA fragment size fraction reflect the tumour burden as well as metabolic activity in advanced NSCLC patients. This suggests their suitability as complementary tests for a more accurate diagnosis of tumour metabolic behaviour and to allow personalised therapies.

Background: The SARS CoV 2 coronavirus pandemic has rocked health care systems to the core. Concurrent circulation of COVID 19 has led to service disruptions and delays in the standard procedures related to lung cancer (LC) diagnose and may negatively impact in the management, care and therapeutic patient intervention. We aimed to determine COVID 19 impact in the molecular diagnosis of LC at our institution. Methods: A total of 203 patients (pts) diagnosed with advanced NSCLC with molecular testing requested in the period of 2019–2020 were included. Clinical characteristics and testing patient results evaluated in 2019 and 2020 were compared. The SOC at our institution includes evaluation of DNA and RNA from tissue(t) and/or blood(b) with NGS or nCounter. Single-gene testing by PCR, IHC and/or FISH is used as complementary assays to NGS when tissue is limited or in case of genomic platform service interruptions. Results: A total of 106 and 97 pts were required for molecular testing during 2019 and 2020 respectively. Clinical patient characteristics in both cohorts were very similar and there were no significant differences in the number of DNA-based or RNA-based analyses required between both period times (DNAt p = 0.25;DNAb p = 0.59;RNAt p =.08). The 2019 cohort identified 66 pts (65%) with driver genes: being KRAS the most commonly detected (34%), followed by EGFR 15%, BRAF 4%, ALK 4% and METΔ14 4%. During 2020, driver alterations were found in 56 pts (60%) in a quite similar proportion except for KRAS mutations, 21%. The total number of non evaluable (NE) samples was significantly increased in 2020 compared to 2019 (p =.029). During 2019, 80% of the NE samples could be evaluated by any multiplex technique. On the contrary, during 2020 only 54% of NE were tested by any NGS-based method. Conclusions: Our results show that molecular diagnosis of LC could be preserved during the COVID 19 outbreak. However genomic service disruptions during critical months of the pandemic clearly impacted in the number of pts with a NE result and might explain the differences in the incidence of KRAS mutations observed. While this global crisis rightly demands the world's attention, a continuous and accurate molecular diagnostic testing must be ensured to guarantee quality-care for LC pts. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: C. Teixido: Honoraria (self), Personal fees: Pfizer;Honoraria (self), Personal fees: Novartis;Honoraria (self), Personal fees: Takeda;Honoraria (self), Personal fees: MSD;Honoraria (self), Personal fees: Roche;Honoraria (self), Personal fees: Diaceutics;Honoraria (self), Personal fees: AstraZeneca;Research grant/Funding (self), Research funding: Pfizer;Research grant/Funding (self), Research funding: Novartis. R. Reyes: Honoraria (self), Speaker Honoraria: Roche;Honoraria (self), Speaker Honoraria: MSD. L. Mezquita: Honoraria (self), Speaker Honoraria: Bristol-Myers Squibb;Honoraria (self), Speaker Honoraria: Tecnofarma;Honoraria (self), Speaker Honoraria: Roche;Honoraria (self), Speaker Honoraria: Takeda;Advisory/Consultancy: Roche Diagnostics;Advisory/Consultancy: Takeda;Advisory/Consultancy: Roche;Travel/Accommodation/Expenses: Bristol-Myers Squibb;Travel/Accommodation/Expenses: Roche;Research grant/Funding (self): Amgen;Research grant/Funding (self): Bristol-Myers Squibb;Research grant/Funding (self): Boehringer Ingelheim;Speaker Bureau/Expert testimony, Mentorship program with key opinion leaders: AstraZeneca. N. Reguart: Honoraria (self), Speaker Honoraria: MSD;Honoraria (self), Speaker Honoraria: BMS;Honoraria (self), Speaker Honoraria: Roche;Honoraria (self), Speaker Honoraria: Boehringer Ingelheim;Honoraria (self), Speaker Honoraria: Guardant Health;Honoraria (self), Speaker Honoraria: Pfizer;Honoraria (self), Speaker Honoraria: AbbVie;Honoraria (self), Speaker Honoraria: Ipsen;Honoraria (self), Speaker Honoraria: Novartis;Honoraria (self), Speaker Honoraria: AstraZeneca;Honoraria (self), Speaker onoraria: Lilly;Honoraria (self), Speaker Honoraria: Takeda;Honoraria (self), Speaker Honoraria: Amgen;Honoraria (self), Organization of educational events: Amgen;Honoraria (self), Organization of educational events: Roche;Advisory/Consultancy: MSD;Advisory/Consultancy: BMS;Advisory/Consultancy: Roche;Advisory/Consultancy: Boehringer Ingelheim;Advisory/Consultancy: Guardant Health;Advisory/Consultancy: Pfizer;Advisory/Consultancy: AbbVie;Advisory/Consultancy: Ipsen;Advisory/Consultancy: Novartis;Advisory/Consultancy: AstraZeneca;Advisory/Consultancy: Lilly;Advisory/Consultancy: Takeda;Advisory/Consultancy: Amgen;Travel/Accommodation/Expenses: Boehringer Ingelheim;Travel/Accommodation/Expenses: MSD;Travel/Accommodation/Expenses: Roche;Research grant/Funding (self): Novartis;Research grant/Funding (self): Pfizer. All other authors have declared no conflicts of interest.

COVID-19 pandemic has dramatically impacted the health national systems, interfering with the access to standard care of other illnesses. However, the real impact of COVID-19 crisis on the cancer care remains unknown. We assessed the access to invasive procedures and critically ill patient units (intensive and intermediate care) in patients with lung cancer hospitalized during pandemic period (during-Covid) compared to the same period in 2019 (before-Covid).

Introduction: Covid-19 pandemic has drastically changed the management of patients with cancer;however, there is still limited data regarding the real impact of Covid-19 on patient’s outcomes due to delayed diagnosis and treatment of clinical complications We aimed to assess the prevalence, severity and mortality of clinical complications and oncology emergencies in hospitalized patients in our institution during the Covid19 period vs the same period of 2019 Methods: We conducted a retrospective study of patients with small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) who were admitted to the Department of Medical Oncology during Jan-Jun 2019 (before-Covid) and Jan-Jun 2020 (Covid-19 period) Clinical, pathological and biological data were collected We assessed the clinical severity in both periods including: PS at admission, progression disease (PD), oncologic emergencies (%), start of a systemic therapy or switch to other therapy line We also analyzed the differences on the 30-day mortality rate since hospitalization between both periods Results: 229 admissions, 133 during and 93 before Covid-19 pandemic (N=180 patients) were enrolled;the median duration of the hospitalization was 9 days (4-16) Median age was 66 years, 35% were female, 88% with PS≥2, 27% were current smokers;83% had NSCLC histology Most of them (82%) had advanced disease at admission;69% were under systemic therapy (chemotherapy 39%, immunotherapy 17%, targeted therapies 11%) Nine patients (4%) were active covid-19 cases (9 NSCLC, 0 SCLC) The table 1 summarized the most common clinical conditions by histology, in both periods In NSCLC population, during-Covid, lower rate of admissions were observed (4 cases less per month), with no increase of oncologic emergencies The PD during hospitalization was slightly higher during vs before-Covid, but no differences were observed in 30-days mortality rate In SCLC population, during-Covid, the rate of admissions was doubled (2 cases more per month), with more cases progressing during the hospitalization (46% during vs 34% before-Covid) In contrast to NSCLC, the 30-days mortality rate was higher during-Covid (38%) vs before-Covid (20%) Updated data will be presented in the meeting [Formula presented] Conclusion: We preliminary observed more aggressive disease with worse outcomes in patients with SCLC hospitalized during-Covid compared to the same period in 2019 No differences were observed in NSCLC The final outcomes will be assessed in a larger and mature cohort still ongoing Keywords: lung cancer, COVID-19, hospitalization

Introduction: Stage IIIB-IV non-small cell lung cancer patients with mutations in the EGF receptor gene (EGFR) usually derive clinical benefit from to tyrosine kinase inhibitors (EGFR TKIs) but ultimately relapse. In preclinical studies, we have showed that anti-EGF antibodies generated by vaccination significantly increased the antitumor activity of TKIs in EGFR-mut cell lines, blocking EGFR, Erk1/2, Akt and STAT3 activation and delaying emergence of resistance. Based on these findings, the EPICAL trial was initiated (ClinicalTrials.gov number, NCT03623750). Methods: The EPICAL was a single arm, phase 1b, single arm study to evaluate the safety and efficacy of first line anti-EGF vaccination combined with afatinib. The trial enrolled advanced NSCLC patients with sensitizing EGFR mutations confirmed in a central laboratory. Patients received 40 mg/day of afatinib and five intramuscular anti-EGF vaccinations every 14 days and then every three months until progression. Four medical centers in Spain participated, with a target enrollment of 30 patients. However, the COVID-19 outbreak forced an early termination of the study in March 2020 with only 23 patients included. Serial blood samples were collected and used to evaluate the levels of selected growth factors by ELISA and biological activity by addition of sera to in vitro cultures of EGFR-mut cells followed by Western blotting. Results: Of the 23 patients enrolled in the trial, nine (39%) had exon 19 in-frame deletions, twelve (52%) exon 21 substitutions and two (9%) exon 18 missense mutations. Combination treatment was well tolerated and no SAES related to anti-EGF vaccination were reported. Objective response and disease control rates were 78.3% (95%CI=53.6-92.5) and 95.7% (95%CI=78.1-99.9), respectively. At data cut-off, with a median follow-up of 11.4 months (95%CI=8.1-15.2), the median progression-free survival was 17.4 months (95% CI=13.22-NA) and median survival not reached (95% CI=15.21-NA). Median PFS for patients with exon 19 deletions and exon 21 point mutations were 13.9 months (95%CI=8.7-NR) and 17.4 months (95%CI=13.2-NR), respectively. Three months after initiation of treatment, high titers of anti-EGF antibodies were detected in all patients and serum EGF and TGFα levels were found to be significantly lower compared to baseline levels. Finally, treatment with post-vaccination patient’s sera inhibited EGFR, AKT and ERK1/2 phosphorylation in EGFR-mut cells growing in vitro. Conclusion: The combination of an anti–EGF vaccine with afatinib is well tolerated and induces a sustained immunogenic effect. Vaccination against EGF might enhance the clinical efficacy of EGFR TKIs. Keywords: anti-EGF vaccination, EGFR-mutant non-small cell lung cancer, EGFR inhibitors