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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

Maria González-Cao,1 Xueting Cai,2 Jilian Wilhelmina Paulina Bracht,3 Xuan Han,2 Yang Yang,2 Carlos Pedraz-Valdunciel,4 Teresa Morán,5 Javier García-Corbacho,6 Andrés Aguilar,1 Reyes Bernabé,7 Pedro De Marchi,8,9 Luciane Sussuchi da Silva,8 Leticia Ferro Leal,8 Rui Manuel Reis,8,10,11 Jordi Codony-Servat,4 Eloisa Jantus-Lewintre,12– 14 Miguel Angel Molina-Vila,4 Peng Cao,2,15 Rafael Rosell1,16 1Translational Cancer Research Unit, Instituto Oncológico Dr Rosell, Dexeus University Hospital, Barcelona, Spain; 2Integrated Traditional Chinese and Western Medicine Department of Affiliated Hospital, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People’s Republic of China; 3Amsterdam University Medical Center (UMC), Amsterdam, The Netherlands; 4Laboratory of Oncology, Pangaea Oncology, Quirón Dexeus University Hospital, Barcelona, Spain; 5Medical Oncology Department, Catalan Institute of Oncology (ICO), Germans Trias i Pujol Hospital, Badalona, Spain; 6Medical Oncology Department (Hospital Clinic)/Translational Genomics and Targeted Therapies in Solid Tumors (IDIBAPs), Barcelona, Spain; 7Medical Oncology Department, Hospital Universitario Virgen del Rocío, Sevilla, Spain; 8Molecular Oncology Research Center; Barretos Cancer Hospital, Barretos, Brazil; 9Oncoclinicas, Rio de Janeiro, Brazil; 10Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; 11ICVS/3b’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal; 12Valencian Community Foundation Principe Felipe Research Center, Laboratory of Molecular Oncology, Valencia, Spain; 13Centro de Investigación Biomédica en Red (CIBERONC), Madrid, Spain; 14Universitat Politècnica de Valencia, Biotechnology Department, Valencia, Spain; 15College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, People’s Republic of China; 16Laboratory of Molecular Biology, Germans Trias i Pujol Health Sciences Institute and Hospital (IGTP), Badalona, SpainCorrespondence: Rafael Rosell, Laboratory of Molecular Biology, Germans Trias i Pujol Health Sciences Institute and Hospital (IGTP), Camí de les Escoless/n, Badalona, Barcelona, 08916, Spain, Tel +34 930330520, Email rrosell@iconcologia.net Peng Cao, College of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, 210023, People’s Republic of China, Tel +86 85608666, Email cao_peng@njucm.edu.cnPurpose: High-mobility group box 1 protein (HMGB1) is subject to exportin 1 (XPO1)-dependent nuclear export, and it is involved in functions implicated in resistance to immunotherapy. We investigated whether HMGB1 mRNA expression was associated with response to immune checkpoint inhibitors (ICI) in non-small cell lung cancer (NSCLC).Patients and Methods: RNA was isolated from pretreatment biopsies of patients with advanced NSCLC treated with ICI. Gene expression analysis of several genes, including HMGB1, was conducted using the NanoString Counter analysis system (PanCancer Immune Profiling Panel). Western blotting analysis and cell viability assays in EGFR and KRAS mutant cell lines were carried out. Evaluation of the antitumoral effect of ICI in combination with XPO1 blocker (selinexor) and trametinib was determined in a murine Lewis lung carcinoma model.Results: HMGB1 mRNA levels in NSCLC patients treated with ICI correlated with progression-free survival (PFS) (median PFS 9.0 versus 18.0 months, P=0.008, hazard ratio=0.30 in high versus low HMGB1). After TNF-α stimulation, HMGB1 accumulates in the cytoplasm of PC9 cells, but this accumulation can be prevented by using selinexor or antiretroviral drugs. Erlotinib or osimertinib with selinexor in EGFR-mutant cells and trametinib plus selinexor in KRAS mutant abolish tumor cell proliferation. Selinexor with a PD-1 inhibitor with or without trametinib abrogates the tumor growth in the murine Lewis lung cancer model.Conclusion: An in-depth exploration of the functions of HMGB1 mRNA and protein is expected to uncover new potential targets and provide a basis for treating metastatic NSCLC in combination with ICI.Keywords: HMGB1, immunotherapy, non-small cell lung cancer, Lewis lung cancer murine model, K-Ras mutations

Manufacturing and characterization of bearing materials is the object of the present work. Thus, graphite particles are added to an aluminium matrix as lubricant. It was added as nickel coated graphite in order to avoid a strength decreasing. Mixing of powders following by cold compaction and hot extrusion was the manufacturing way. Extruded materials showed good graphite distribution into the aluminium matrix, with densities between 3.11 to 3.75 g/cm3 as a function of the nickel/graphite content. Hardness and radial crushing strength decrease when graphite content is increased. On the contrary, friction properties are improved with the graphite content because it decreases friction coefficient and wear. Diffusion heat treatment on extruded materials improves furthermore these friction properties but it decreases the radial crushing strength.El objeto de este trabajo es la obtención y caracterización de materiales compuestos (MMC´s) para la fabricación de cojinetes para fricción en seco. Así se incorpora a una matriz de aluminio, partículas de grafito para actuar como lubricante si bien en forma de grafito recubierto de níquel para disminuir la perdida de resistencia que presentan estos materiales. La fabricación de estos materiales se realizó mediante compactación de las mezclas de polvos en matriz y su extrusión en caliente. Los materiales obtenidos presentaron una buena distribución del grafito en la matriz de aluminio, con densidades entre 3.11 g/cm3 y 3.75 g/cm3 según el contenido de níquel/grafito. La dureza y la resistencia al aplastamiento radial disminuyen al aumentar el contenido en grafito. No obstante, un mayor contenido en grafito si mejora las propiedades a fricción del material, disminuyendo el desgaste ocasionado y reduciendo el coeficiente de fricción. El tratamiento térmico de difusión de los materiales extruidos mejora sus propiedades de fricción si bien disminuye su resistencia al aplastamiento radial.

BackgroundAnti-PD1/PD-L1 directed immune checkpoint inhibitors (ICI) are widely used to treat patients with advanced non-small-cell lung cancer (NSCLC). The activity of ICI across NSCLC harboring oncogenic alterations is poorly characterized. The aim of our study was to address the efficacy of ICI in the context of oncogenic addiction.Patients and methodsWe conducted a retrospective study for patients receiving ICI monotherapy for advanced NSCLC with at least one oncogenic driver alteration. Anonymized data were evaluated for clinicopathologic characteristics and outcomes for ICI therapy: best response (RECIST 1.1), progression-free survival (PFS), and overall survival (OS) from ICI initiation. The primary end point was PFS under ICI. Secondary end points were best response (RECIST 1.1) and OS from ICI initiation.ResultsWe studied 551 patients treated in 24 centers from 10 countries. The molecular alterations involved KRAS (n = 271), EGFR (n = 125), BRAF (n = 43), MET (n = 36), HER2 (n = 29), ALK (n = 23), RET (n = 16), ROS1 (n = 7), and multiple drivers (n = 1). Median age was 60 years, gender ratio was 1 : 1, never/former/current smokers were 28%/51%/21%, respectively, and the majority of tumors were adenocarcinoma. The objective response rate by driver alteration was: KRAS = 26%, BRAF = 24%, ROS1 = 17%, MET = 16%, EGFR = 12%, HER2 = 7%, RET = 6%, and ALK = 0%. In the entire cohort, median PFS was 2.8 months, OS 13.3 months, and the best response rate 19%. In a subgroup analysis, median PFS (in months) was 2.1 for EGFR, 3.2 for KRAS, 2.5 for ALK, 3.1 for BRAF, 2.5 for HER2, 2.1 for RET, and 3.4 for MET. In certain subgroups, PFS was positively associated with PD-L1 expression (KRAS, EGFR) and with smoking status (BRAF, HER2).Conclusions: ICI induced regression in some tumors with actionable driver alterations, but clinical activity was lower compared with the KRAS group and the lack of response in the ALK group was notable. Patients with actionable tumor alterations should receive targeted therapies and chemotherapy before considering immunotherapy as a single agent.

Niki Karachaliou,1,2 Manuel Fernandez Bruno,1 Jillian Wilhelmina Paulina Bracht,2 Rafael Rosell2–51Institute of Oncology Rosell (IOR), University Hospital Sagrat Cor, QuironSalud Group, Barcelona, Spain; 2Molecular and Cellular Oncology Laboratory, Pangaea Oncology, Laboratory of Molecular Biology, Quiron-Dexeus University Institute, Barcelona, Spain; 3Institut d’Investigació en Ciències Germans Trias i Pujol, Badalona, Spain; 4Catalan Institute of Oncology, Medical Oncology Service, Hospital Germans Trias i Pujol, Badalona, Spain; 5Instituto Oncológico Dr Rosell (IOR), Quirón-Dexeus University Institute, Barcelona, SpainAbstract: Discovered in 2007, anaplastic lymphoma kinase (ALK) gene rearrangements positive (ALK+) lung cancers compose a small subset of non-small cell lung cancer (NSCLC), with rapidly expanded treatments. There are currently several ALK inhibitors, including crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib which have been licensed by the US Food and Drug Administration or the European Medicines Agency for the treatment of ALK+ NSCLC patients. Along with the multiple therapies, the survival of this subtype of NSCLC has been significantly expanded, even for patients whose disease has spread in the brain. Alectinib (Alecensa), a specific ALK and rearranged during transfection tyrosine kinase inhibitor is approved as first-line therapy for metastatic ALK+ NSCLC patients. It is additionally approved for ALK+ NSCLC previously treated with crizotinib. The main aim of this review is to assemble on the efficacy of alectinib for the treatment of ALK+ NSCLC, to elaborate the activity of the drug in the central nervous system, and to debate on which is the position of this compound in the treatment course of ALK+ lung cancer patients.Keywords: anaplastic lymphoma kinase, alectinib, lung cancer

Cristina Aguado,1,* Maria-de-los-Llanos Gil,2,* Zaira Yeste,1 Ana Giménez-Capitán,1 Cristina Teixidó,1 Niki Karachaliou,2 Santiago Viteri,2 Rafael Rosell,1,2 Miguel A Molina-Vila1 1Laboratory of Oncology, Pangaea Oncology, 2Dr Rosell Oncology Institute, Quirón Dexeus University Hospital, Barcelona, Spain *These authors contributed equally to this work Abstract: Fusion of the anaplastic lymphoma receptor tyrosine kinase gene (ALK) with the echinoderm microtubule-associated protein 4 gene (EML4) is the second most common actionable alteration in non-small-cell lung cancer, with a frequency of 5%. Here, we present a case of an EML4-ALK-positive patient with an atypical in-frame insertion from the LTBP1 gene in the canonical junction of variant 1. The patient was a 39-year-old never-smoker female diagnosed with Stage IV lung adenocarcinoma. A core biopsy was negative for EGFR and KRAS mutations but positive for ALK immunohistochemistry and fluorescence in situ hybridization. When submitted to nCounter, the sample showed a 3'/5' imbalance indicative of an ALK rearrangement, but failed to give a positive signal for any of the variants tested. Finally, a band with a molecular weight higher than expected appeared after reverse transcriptase-polymerase chain reaction analysis. When Sanger sequencing was performed, the band revealed an atypical EML4-ALK fusion gene with an in-frame 129 bp insertion. A 115 bp segment of the insertion corresponded to an intronic region of LTBP1, a gene located in the short arm of chromosome 2, between ALK and EML4. The patient received crizotinib and showed a good therapeutic response that is still ongoing after 12 months. Our result suggests that short in-frame insertions of other genes in the EML4-ALK junction do not affect the sensitivity of the EML4-ALK fusion protein to crizotinib. Keywords: lung cancer, NSCLC, EML4-ALK, LTBP1, crizotinib, targeted therapy

Mariacarmela Santarpia,1 Alessia Liguori,1 Niki Karachaliou,2 Maria Gonzalez-Cao,3 Maria Grazia Daffinà,1 Alessandro D’Aveni,1 Grazia Marabello,1 Giuseppe Altavilla,1 Rafael Rosell3–5 1Medical Oncology Unit, Department of Human Pathology “G. Barresi”, University of Messina, Messina, Italy; 2Institute of Oncology Rosell (IOR), University Hospital Sagrat Cor, 3Department of Oncology, Institute of Oncology Rosell (IOR), Quirón-Dexeus University Institute, Barcelona, 4Cancer Biology and Precision Medicine Program, Germans Trias i Pujol Research Institute, 5Catalan Institute of Oncology, Germans Trias i Pujol University Hospital, Badalona, Spain Abstract: The discovery of epidermal growth factor receptor (EGFR) mutations and subsequent demonstration of the efficacy of genotype-directed therapies with EGFR tyrosine kinase inhibitors (TKIs) marked the advent of the era of precision medicine for non-small-cell lung cancer (NSCLC). First- and second-generation EGFR TKIs, including erlotinib, gefitinib and afatinib, have consistently shown superior efficacy and better toxicity compared with first-line platinum-based chemotherapy and currently represent the standard of care for EGFR-mutated advanced NSCLC patients. However, tumors invariably develop acquired resistance to EGFR TKIs, thereby limiting the long-term efficacy of these agents. The T790M mutation in exon 20 of the EGFR gene has been identified as the most common mechanism of acquired resistance. Osimertinib is a third-generation TKI designed to target both EGFR TKI-sensitizing mutations and T790M, while sparing wild-type EGFR. Based on its pronounced clinical activity and good safety profile demonstrated in early Phase I and II trials, osimertinib received first approval in 2015 by the US FDA and in early 2016 by European Medicines Agency for the treatment of EGFR T790M mutation-positive NSCLC patients in progression after EGFR TKI therapy. Recent results from the Phase III AURA3 trial demonstrated the superiority of osimertinib over standard platinum-based doublet chemotherapy for treatment of patients with advanced EGFR T790M mutation-positive NSCLC with disease progression following first-line EGFR TKI therapy, thus definitively establishing this third-generation TKI as the standard of care in this setting. Herein, we review preclinical findings and clinical data from Phase I–III trials of osimertinib, including its efficacy in patients with central nervous system metastases. We further discuss currently available methods used to analyze T790M mutation status and the main mechanisms of resistance to osimertinib. Finally, we provide an outlook on ongoing trials with osimertinib and novel therapeutic combinations that might continue to improve the clinical outcome of EGFR-mutated NSCLC patients. Keywords: osimertinib, T790M mutation, epidermal growth factor receptor, tyrosine kinase inhibitors

María González-Cao,1 Niki Karachaliou,1 Santiago Viteri,1 Daniela Morales-Espinosa,1 Cristina Teixidó,2 Jesús Sánchez Ruiz,3 Miquel Ángel Molina-Vila,2 Mariacarmela Santarpia,4 Rafael Rosell1,2,5,61Translational Cancer Research Unit, Instituto Oncológico Dr Rosell, Quirón Dexeus University Hospital, Barcelona, Spain; 2Pangaea Biotech SL, Barcelona, Spain; 3Centro Nacional de Investigación Oncología (CNIO), Madrid, Spain; 4Medical Oncology Unit, Human Pathology Department, University of Messina, Messina, Italy; 5Cancer Biology and Precision Medicine Program, Catalan Institute of Oncology, Germans Trias i Pujol Health Sciences Institute and Hospital, Campus Can Ruti, Badalona, Barcelona, Spain; 6Fundación Molecular Oncology Research, Barcelona, SpainAbstract: Increased understanding of tumor immunology has led to the development of effective immunotherapy treatments. One of the most important advances in this field has been due to pharmacological design of antibodies against immune checkpoint inhibitors. Anti-PD-1/PD-L1 antibodies are currently in advanced phases of clinical development for several tumors, including lung cancer. Results from Phase I–III trials with anti-PD-1/PD-L1 antibodies in non-small-cell lung cancer have demonstrated response rates of around 20% (range, 16%–50%). More importantly, responses are long-lasting (median duration of response, 18 months) and fast (50% of responses are detected at time of first tumor evaluation) with very low grade 3–4 toxicity (less than 5%). Recently, the anti-PD-1 antibody pembrolizumab received US Food and Drug Administration (FDA) breakthrough therapy designation for treatment of non-small-cell lung cancer, supported by data from a Phase Ib trial. Another anti-PD-1 antibody, nivolumab, has also been approved for lung cancer based on survival advantage demonstrated in recently released data from a Phase III trial in squamous cell lung cancer.Keywords: immunotherapy, immunoncology, cancer, checkpoint inhibitors

Niki Karachaliou,1 Rafael Rosell21Translational Research Unit, Dr Rosell Oncology Institute, Quirón Dexeus University Hospital, 2Cancer Biology and Precision Medicine Program, Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Barcelona, SpainAbstract: Deeper understanding of the pathobiology of non-small-cell lung cancer (NSCLC) has led to the development of small molecules that target genetic mutations known to play critical roles in the progression to metastatic disease. The discovery of epidermal growth factor receptor (EGFR) mutations in 15%–20% of lung adenocarcinomas and the associated response to EGFR tyrosine kinase inhibitors have provided a successful avenue of attack in late-stage adenocarcinomas. Use of the EGFR tyrosine kinase inhibitors gefitinib, erlotinib, and afatinib is limited to patients who have adenocarcinomas with known activating EGFR mutations. However, the EGFR mutation testing landscape is varied and includes many screening and targeted methods, each with its own benefits and limitations. These tests can simplify the drug discovery process, make clinical trials more efficient and informative, and individualize cancer therapy. In practice, the choice of method should be determined by the nature of the sample to be tested, the testing laboratory's expertise and access to equipment, and whether the detection of only known activating EGFR mutations, or of all possible mutations, is required. Development of companion diagnostic tests for this identification is advancing; nevertheless, the use of such tests merits greater attention.Keywords: lung adenocarcinoma, EGFR mutations, companion diagnostics