Roberto Serna-Blasco

Purpose:Perioperative chemoimmunotherapy is the standard of care for resectable, locally advanced non–small cell lung cancer (NSCLC). Although pathologic complete response (pCR) correlates with excellent survival outcomes, some patients without pCR still exhibit long-term survival. In this study, we evaluate the added value of minimal residual disease (MRD).Experimental Design:MRD was assessed in 60 patients from the NADIM II trial (NCT03838159) using the Guardant Reveal assay. In NADIM II, patients with NSCLC without EGFR or ALK alterations were randomly assigned to receive neoadjuvant nivolumab plus chemotherapy (experimental arm) or chemotherapy alone, followed by surgery. Patients in the experimental arm with R0 resection received adjuvant nivolumab.Results:The MRD detection rate was 9.6%. MRD after surgery or during adjuvant treatment was associated with inferior event-free survival (EFS) and overall survival [OS; hazard ratio (HR): 10.2; 95% confidence interval (CI), 3.7–28.3 and HR: 10.0; 95% CI, 2.0–49.9, respectively]. All patients with MRD-negative plasma samples in at least two time points were alive [HR: not estimable (NE), P < 0.001], with only one relapse (HR: 41.6; 95% CI, 5.0–348.8), corresponding to a patient relapsing with a single brain metastasis. MRD enhanced the prognostic value of pCR for both EFS (P < 0.001) and OS (P = 0.015). Among non-pCR patients, MRD remained a significant prognostic marker (HR: 6.2; 95% CI, 2.2–17.1 and HR: 6.5; 95% CI, 1.3–32.5, for EFS and OS respectively). All non-pCR patients with MRD-negative results in at least two time points were alive (HR: NE, P = 0.025), with one relapse (HR: 19.9; 95% CI, 2.4–165.6), corresponding to the aforementioned case.Conclusions:MRD may refine prognostic evaluation beyond pCR in resectable NSCLC undergoing perioperative chemoimmunotherapy.

Supplementary Figure 1. Study design and MRD sampling scheme of the NADIM II trial. Patient numbers shown for each treatment arm indicate the number of patients for whom MRD analysis was performed.

Supplementary figure 3. Incremental prognostic value of MRD status beyond pathological response in multivariable models. Likelihood ratio (LR) tests show the added predictive contribution of MRD (defined as detection in at least two samples) when incorporated into models including pathological response for (A) event-free survival (EFS) and (B) overall survival (OS). P values from likelihood ratio tests are indicated above each plot.

Supplementary table 1. Non–cancer-related deaths, including treatment arm, surgical resection status, pathological response, and reported cause of death.

Supplementary Figure 2. Kaplan–Meier curves for event-free survival (EFS) and overall survival (OS) according to minimal residual disease (MRD) status. (A) EFS in the experimental arm. (B) OS in the experimental arm. (C) EFS in the control arm. (D) OS in the control arm. MRD positivity was defined as MRD detection at any time point. Hazard ratios (HR) with 95% confidence intervals were estimated using Cox proportional hazards models, and P values were calculated with the log-rank test.

Supplementary figure 4. Kaplan–Meier curves for (A) event-free survival (EFS) and (B) overall survival (OS) in non-pCR patients according to MRD status. MRD positivity was defined as detection at any time point. Hazard ratios (HRs) and 95% confidence intervals were estimated with Cox proportional hazards models, and P values were derived from log-rank tests, as indicated in each plot. Abbreviations: pCR, pathological complete response; MRD, minimal residual disease.

Purpose: Perioperative chemoimmunotherapy is the standard of care for resectable, locally advanced non–small cell lung cancer (NSCLC). Although pathologic complete response (pCR) correlates with excellent survival outcomes, some patients without pCR still exhibit long-term survival. In this study, we evaluate the added value of minimal residual disease (MRD). Experimental Design: MRD was assessed in 60 patients from the NADIM II trial (NCT03838159) using the Guardant Reveal assay. In NADIM II, patients with NSCLC without EGFR or ALK alterations were randomly assigned to receive neoadjuvant nivolumab plus chemotherapy (experimental arm) or chemotherapy alone, followed by surgery. Patients in the experimental arm with R0 resection received adjuvant nivolumab. Results: The MRD detection rate was 9.6%. MRD after surgery or during adjuvant treatment was associated with inferior event-free survival (EFS) and overall survival [OS; hazard ratio (HR): 10.2; 95% confidence interval (CI), 3.7–28.3 and HR: 10.0; 95% CI, 2.0–49.9, respectively]. All patients with MRD-negative plasma samples in at least two time points were alive [HR: not estimable (NE), P < 0.001], with only one relapse (HR: 41.6; 95% CI, 5.0–348.8), corresponding to a patient relapsing with a single brain metastasis. MRD enhanced the prognostic value of pCR for both EFS (P < 0.001) and OS (P = 0.015). Among non-pCR patients, MRD remained a significant prognostic marker (HR: 6.2; 95% CI, 2.2–17.1 and HR: 6.5; 95% CI, 1.3–32.5, for EFS and OS respectively). All non-pCR patients with MRD-negative results in at least two time points were alive (HR: NE, P = 0.025), with one relapse (HR: 19.9; 95% CI, 2.4–165.6), corresponding to the aforementioned case. Conclusions: MRD may refine prognostic evaluation beyond pCR in resectable NSCLC undergoing perioperative chemoimmunotherapy.

Background: Neoadjuvant chemoimmunotherapy for non-small cell lung cancer (NSCLC) has improved pathological responses and survival rates compared with chemotherapy alone, leading to Food and Drug Administration (FDA) approval of nivolumab plus chemotherapy for resectable stage IB-IIIA NSCLC (AJCC 7th edition) without ALK or EGFR alterations. Unfortunately, a considerable percentage of tumors do not completely respond to therapy, which has been associated with early disease progression. So far, it is impossible to predict these events due to lack of knowledge. In this study, we characterized the gene expression profile of tumor samples to identify new biomarkers and mechanisms behind tumor responses to neoadjuvant chemoimmunotherapy and disease recurrence after surgery. Methods: Tumor bulk RNA sequencing was performed in 16 pretreatment and 36 post-treatment tissue samples from 41 patients with resectable stage IIIA NSCLC treated with neoadjuvant chemoimmunotherapy from NADIM trial. A panel targeting 395 genes related to immunological processes was used. Tumors were classified as complete pathological response (CPR) and non-CPR, based on the total absence of viable tumor cells in tumor bed and lymph nodes tested at surgery. Differential-expressed genes between groups and pathway enrichment analysis were assessed using DESeq2 and gene set enrichment analysis. CIBERSORTx was used to estimate the proportions of immune cell subtypes. Results: CPR tumors had a stronger pre-established immune infiltrate at baseline than non-CPR, characterized by higher levels of IFNG, GZMB, NKG7, and M1 macrophages, all with a significant area under the receiver operating characteristic curve (ROC) >0.9 for CPR prediction. A greater effect of neoadjuvant therapy was also seen in CPR tumors with a reduction of tumor markers and IFNγ signaling after treatment. Additionally, the higher expression of several genes, including AKT1, BST2, OAS3, or CD8B; or higher dendritic cells and neutrophils proportions in post-treatment non-CPR samples, were associated with relapse after surgery. Also, high pretreatment PD-L1 and tumor mutational burden levels influenced the post-treatment immune landscape with the downregulation of proliferation markers and type I interferon signaling molecules in surgery samples. Conclusions: Our results reinforce the differences between CPR and non-CPR responses, describing possible response and relapse immune mechanisms, opening the possibility of therapy personalization of immunotherapy-based regimens in the neoadjuvant setting of NSCLC.