Management of non-small cell lung cancer in the era of personalized medicine

Accepted Manuscript Title: Management of Non-small cell lung cancer in the era of personalized medicine. Authors: Gaetano Rocco MD, FRCSEd Alessandro Morabito MD Alessandra Leone PhD Paolo Muto MD Francesco Fiore MD Alfredo Budillon MD, PhD PII: DOI: Reference:

S1357-2725(16)30183-2 http://dx.doi.org/doi:10.1016/j.biocel.2016.07.011 BC 4903

To appear in:

The International Journal of Biochemistry & Cell Biology

Received date: Revised date: Accepted date:

16-3-2016 11-7-2016 13-7-2016

Please cite this article as: Rocco, Gaetano., Morabito, Alessandro., Leone, Alessandra., Muto, Paolo., Fiore, Francesco., & Budillon, Alfredo., Management of Non-small cell lung cancer in the era of personalized medicine.International Journal of Biochemistry and Cell Biology http://dx.doi.org/10.1016/j.biocel.2016.07.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Management of Non-small cell lung cancer in the era of personalized medicine.

Gaetano Rocco1, MD, FRCSEd, Alessandro Morabito2, MD, Alessandra Leone3, PhD, Paolo Muto4, MD, Francesco Fiore5, MD, Alfredo Budillon3*, MD, PhD

1

Divisions of Thoracic Surgery, 2Medical Oncology, 3Experimental Pharmacology, 4Radiation

Oncology, 5Interventional Radiology, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' – IRCCS, Napoli, Italy.

*

Address for correspondence:

Alfredo Budillon Experimental Pharmacology Unit Istituto Nazionale Tumori “Fondazione G. Pascale” – IRCCS Via M. Semmola 80131, Napoli, Italy. Tel: +390815903292 [email protected]

Abstract Despite major advances in the molecular definition of the disease, screening and therapy, nonsmall cell lung cancer (NSCLC) is still characterized by a disappointing overall survival, depending on subtype and tumor stage. To address this challenge, in the last years the therapeutic algorithm of NSCLC has become much more complex and articulated, with different kinds of drugs, including chemotherapy, targeted-based agents, angiogenesis inhibitors and immunotherapy, and multiple lines of treatments, for patients with squamous and non-squamous hystology, EGFR mutation and ALK rearrangement. This short viewpoint describes the emerging strategies for the management of NSCLC, indicating how a personalized approach, characterized by a specific multidisciplinary involvement, implies a process that starts with early detection and includes surgery and systemic therapy.

Keywords: non-small cell lung cancer (NSCLC), personalized medicine, EGFR, ALK, early detection, video-assisted thoracoscopic surgery (VATS), stereotactic ablative radiotherapy (SABR), Immunotherapy.

1.1 Introduction The concept of individualized or personalized medicine originates from the appreciation of patient specific features amenable to dedicated diagnostic and/or therapeutic steps (Novello, Asamura et al. 2014). In this setting, personalized medicine is characterized by a specific multidisciplinary involvement in as much as it can be applied to different fields of the same clinical or research domain, such as surgery, genomic profiling or chemotherapy in the management of non-small cell lung cancer (NSCLC) (Novello, Asamura et al. 2014). The personalization of the approach to lung cancer patients implies a process that starts with early detection and includes surgery and systemic therapy (Novello, Asamura et al. 2014). The final objective of a personalized approach is to improve a disappointing overall survival, depending on subtype and tumor stage, that, despite major advances in the molecular definition of the disease, screening and therapy, still characterized this type of tumors (Siegel, Miller et al. 2016). NSCLC accounts up to 85% of all cases of lung cancer and is actually considered as the leading cause of cancer death worldwide in both men and women. Smoking remains the major cause of NSCLC, although the identification of driver oncogenes in non-smoking patients represent a critical novel findings in last decades that changed the management of this disease. NSCLC is a highly heterogeneous disease that can be classified in different subtypes, based on different area of bronchial tree they arise: squamous cell lung cancer (SCC), adenocarcinoma (AdenoCa) and large cell anaplastic carcinomas (LCAC) (Boolell, Alamgeer et al. 2015, Chatziandreou, Tsioli et al. 2015). AdenoCa arise from the peripheral bronchi and to date represent the most frequent subtype, accounting for almost 40% of lung cancers. In recent years, given its origin in the alveoli, also the formerly termed bronchioloalveolar cancer has been included in this subtype. However, this definition is currently abandoned and the terms adenoCa in situ and minimally invasive adenoCa, referring to two separate histopathological entitites, are preferred (Travis, Brambilla et al. 2011). Conversely, SCC and LCAC, representing 25-30% (SCC) and 10-

15% (LCAC) of all lung cancers, respectively, may derive either from the the main bronchi or the proximal bronchial tree (Boolell, Alamgeer et al. 2015, Lemjabbar-Alaoui, Hassan et al. 2015). However, the rapid increase in the knowledge of NSCLC molecular biology led to reconsider the classification into molecular subtypes, particularly regarding AdenoCa and SCC subgroups (Boolell, Alamgeer et al. 2015). The two main alterations in driver oncogenes identified in AdenoCa tumorigenesis are the mutations of the epidermal growth factor receptor (EGFR) and the activated anaplastic lymphoma kinase (ALK) genes. About 15% of Caucasian patients and 40–50% of Asian patients with lung adenocarcinoma harbor mutations in the EGFR gene, commonly localized into the tyrosine kinase domain (i.e. deletion in exon19, missense mutation L858R in exon 21 and others), that lead to constitutive activation of EGFR-mediated signaling. The rearrangement of ALK with the echinoderm microtubule-associated protein-like 4 (EML4) gene is reported in 3-7% of NSCLC patients and yield the formation of the EML4-ALK fusion kinase, a potent oncogenic driver involved in cell proliferation as well as apoptosis inhibition (Kumar, Ernani et al. 2015, Lemjabbar-Alaoui, Hassan et al. 2015). RAS mutation, and specifically in the KRAS gene, occurs in almost 15-30% of lung cancers and leads to increase tumorigenesis, by modulating several pro-tumorigenic pathways (Zhang, Park et al. 2016). Other rare genetic mutations (incidence rate of 1-3%), including alterations in ROS1, MET, RET, BRAF and Her2 genes, have been reported in a small subset of NSCLC patients (Mitsudomi, Suda et al. 2013, Chatziandreou, Tsioli et al. 2015, Kumar, Ernani et al. 2015). Some of these genetic alterations, such as K-Ras, are generally reported concomitantly with others, suggesting that they should be considered “passenger” rather than driver mutations. Others, although suggested to be mutually exclusive (i.e. EGFR and EML4-ALK), have been recently described within a single tumor,, leading to an increasing trouble to identify driver oncogenes and, consequentially, to choose the right therapeutical approach (Tiseo, Gelsomino et al. 2011, Won, Keam et al. 2015, Lee, Lee et al. 2016) In SCC subtype, the most frequent alteration is the hyper-activation of Phosphoinositide 3-kinase catalytic α (PI3KCA) gene that confers tumor growth advantage. Interestingly, this gene is located close to the SOX2 lineage transcription factor gene that is frequently amplified in SCC. However, it

is still unknown if the two mechanisms are functionally interdependent (Perez-Moreno, Brambilla et al. 2012). Other alterations in Fibroblast growth factor receptor 1 (25% of SCC), the discoidin domain receptor 2 (DDR2) (4% of SCC) and MET (6% of SCC) genes, have been identified in SCC patients as potentially targetable drivers mutations (Boolell, Alamgeer et al. 2015). To date, the identification of histological and/or the molecular NSCLC subtypes appears of critical importance to define a personalized treatment for each patient and to improve the prognosis.

1.2 Lung cancer early detection With the demonstration of a significant 20% reduction of lung cancer specific mortality in patients subjected to low density computed tomography of the chest (LDCT) in the setting of the National Lung Screening Trial (NLST) and the subsequent decision by the United States Preventative Services Task Force (USPSTF) to accept LDCT screening for insurance coverage in high risk population, the need for a personalized approach in the management of screen detected nodules has been emphasized (National Lung Screening Trial Research, Aberle et al. 2011, Moyer and Force 2014). Apart from the potential harms related to LDCT screening programs (resulting from radiation, false positives, psychological, and, financial), health care provider costs have represented a serious counterargument against implementing such programs at a national level (de Koning, Meza et al. 2014). One of the major issues to be addressed in the creation of a lung cancer screening program relates to the population considered at high risk for developing lung cancer (Raji, Duffy et al. 2012). Several models have been proposed throughout the years to refine the assessment of the individual risk (Field, Oudkerk et al. 2013, Tammemagi, Katki et al. 2013). The model proposed within the United Kingdom Lung Cancer Screening Program (UKLS) is mutuated from the Liverpool Lung Project (LLP) and focuses on a 5 year, 5% estimated threshold for lung cancer risk (Cassidy, Myles et al. 2008). A composite score, taking into account multiple variables, such as age, smoking history, family history of lung cancer, previous malignancies, occupational exposure, pneumonia and asbestos exposure, is useful in determining eligibility for LDCT screening (Cassidy, Myles et al. 2008). By reducing the age range of the population at risk from 54 to 74 years (NLST) to 60 to 74 years (UKLS) and the frequency of screening (ie, from

annual to biennial), between 800 and 1,400 lives would be saved in the UK every year with an acceptable cost of 24,000 $ per quality adjusted life-year (Field, Oudkerk et al. 2013). The resort to volumetric measurement as opposed to diametric measurement by means of appropriate imaging softwares has streamlined the categorization of screen detected nodules and allowed to identify only 3 risk groups according to the nodule size (Buckler, Mulshine et al. 2010, Field, Oudkerk et al. 2013). Additional personalized measures to minimize the risk for overdiagnosis and LDCT-related false positives include titration of miRNA or breathanalysis (Sozzi, Boeri et al. 2014, Rocco, Incalzi et al. 2015). The former has revealed the ability to reduce to 3.5% from 24% the false positive rates whereas the latter is able to reliably identify lung cancer signatures in the exalates of screened individuals, thus making further stratification of high risk candidates possible (Sozzi, Boeri et al. 2014) . 1.3 Surgery for lung cancer In the last decades, while minimally invasive techniques have expanded the surgical armamentarium to an unprecedented level, the most recent advancements on preoperative risk assessment have identified new thresholds for operability (Brunelli, Charloux et al. 2009, Klapper and D'Amico 2015). In turn, the combination of improved operability and reduction of surgical invasiveness allowed for individualization of the surgical treatment of early stage NSCLC (Rocco, Allen et al. 2013). This translated into a distinct possibility to offer a surgical option to more patients than in the past, of older age groups and characterized by a wider range of comorbidities (Brunelli, Charloux et al. 2009, Paul, Altorki et al. 2010). In addition, the refinement of the anesthetic techniques has paved the way to performing an increasing number of minimally invasive surgical procedures in the awake or non-intubated patients (Gonzalez-Rivas, Bonome et al. 2016, Rocco 2016). This complex chain of events leads to fast-tracking of patients through hospitalizations, the duration of which has been significantly curtailed compared to 20 years ago (Salati, Brunelli et al. 2012). In practical terms, each individual patient can receive an appropriate, tailor-made, surgical treatment which is only intended to pursue the same oncologic principles as traditional approaches with the least invasiveness. Moreover, a secondary result obtained by this new therapeutic strategy consisted in the reduction of costs sustained to complete the diagnostic/therapeutic

pathway for any single patient (Shamji and Deslauriers 2013). In fact, the unrestricted resort to the endoscopic histological diagnosis/staging of NSCLC with endobronchial ultrasonography (EBUS) or electromagnetic navigational bronchoscopy (ENB) biopsy has obviated to the need for unnecessary thoracotomic surgical approaches (Trisolini, Cancellieri et al. 2015, Ng, Yu et al. 2016). The latter two diagnostic procedures can be considered as precursors of the single entry port video-assisted technique (“Uniportal” video-assisted thoracoscopic surgery or VATS) (Rocco, Martucci et al. 2013, Xie, Wang et al. 2016). Uniportal VATS is rapidly gaining favor among surgeons worldwide due to its use for every possible diagnostic and therapeutic scenario where a thoracic surgical procedure is needed (Gonzalez-Rivas, Aymerich et al. 2015). The clinical consequence of this surgical revolution is the previously unconceivable realization of diagnostic or therapeutic pathways conducted in an outpatient setting. Accordingly, individualized medicine is embodied by the use of an ad hoc minimally invasive surgical procedures which can be performed either under general or loco-regional anesthesia and entail very short hospitalizations and limited costs. Nonetheless, the next frontier is the use of genomic editing in combination with minimally invasive thoracic surgery (Mahar, Compton et al. 2015, Tang and Shrager 2016). This form of personalized molecular surgical therapy will allow repair or deletion of resistant EGFR mutated genes obtained from surgical bioptic specimens by means of induced genomic editing packages (Tang and Shrager 2016). The latter can be inserted into viral structured and then injected intratracheally, for localized cancers, or into the bloodstream, in the event of metastatic dissemination (Tang and Shrager 2016). 1.4 Alternative treatment modalities to surgery to obtain local control of NSCLC In recent years, stereotactic ablative radiotherapy (SABR) has been proposed as alternative to surgical treatment to gain satisfactory local control of NSCLC (Senan, Paul et al. 2013). Whereas the value of SABR in inoperable patients or in patients who refuse surgery is commonly accepted, its use for small, peripheral lung cancers in patients who could be otherwise surgical candidates is debated (Puri, Crabtree et al. 2015). In fact, the lack of an histological diagnosis in up to 65% of patients subjected to SABR, the potential lack of thoracic surgical input in the decision making process, the difficult comparison between clinical (SABR) and pathological (surgery) stages, and,

the lack of tissue specimen for biomolecular assessment make a viable comparison difficult, if not impossible (Senan, Paul et al. 2013) . On the other hand, prospective, randomized trials of SABR vs surgery have consistently failed to recruit and had to be prematurely stopped albeit controversial ad hoc analyses have been proposed in the literature only to rise substantial criticism as to the methodology and the reliability of results (Chang, Senan et al. 2015, Opitz, Rocco et al. 2015). Nevertheless, SABR should be considered as the primary alternative to lung cancer surgery to be taken into consideration during multidisciplinary discussions. Radiofrequency ablation (RFA) of lung lesions represents a valuable additional tool in the quest for local control of NSCLC (Hinshaw, Lubner et al. 2014, Zheng, Wang et al. 2014, Smith and Jennings 2015). The potential advantage of this procedure is that it can be performed at the same time as fine needle aspiration biopsy for diagnosis of a suspected mass lesion in the lung (Hinshaw, Lubner et al. 2014, Zheng, Wang et al. 2014, Smith and Jennings 2015). There are two groups of patients for whom percutaneous tumor ablation can currently be considered: patients with early-stage primary (non-small-cell) lung cancer with no lymph node metastasis who are not candidates for surgery as a result of comorbidity; patients with pulmonary metastases who are not candidates for curative resection of metastases or those with a limited number of pulmonary metastases, as part of palliative care. Peripherally localized tumors < 3 cm in diameter are the most promising targets of RFA. The evolution of RFA technology has now yielded to the use of microwave thermoablation that is at the same time, effective, in limiting the damage to the actual lesion, and, in experienced hands, relatively devoid of major complications (Hinshaw, Lubner et al. 2014, Zheng, Wang et al. 2014, Smith and Jennings 2015). As for SABR, the advantage of thermoablation resides in the potential reduction of post-treatment morbidity and length of hospital stay since both procedures can be done in an outpatient setting (Hinshaw, Lubner et al. 2014, Zheng, Wang et al. 2014, Smith and Jennings 2015). However, the lack of long –term reliable results argues against considering these treatments, at this time, as front-line management modalities of otherwise operable and resectable NSCLC.

1.5 Personalized medical therapy for lung cancer

The recognition that NSCLC is not a single disease entity is to date a well-known reality that has led to divide NSCLC in different categories, each one with specific algorithms of treatment, based on histological and molecular features. These consideration highlighted the importance of definition of biomarkers, either as predictive of treatment response or as prognostic irrespective of treatment intervention (Kumar, Ernani et al. 2015). Histology represented the first example of surrogate biomarker useful to avoid specific therapeutic approach that can impact either on the safety or on the efficacy of the therapy. The most reported example regards the squamous histology, which usually is not treated with angiogenic drugs. Indeed, several clinical trials reported a wide spectrum of side effects in squamous patients treated with bevacizumab, while pemetrexed is avoid in patients with squamous histology, since superior benefit treatment in non-squamous cell histology (Langer, Besse et al. 2010): However, the last decade identified NSCLC genetic alterations as useful prognostic or predictive biomarkers. To date, the presence of both activating-mutations in the EGFR gene or the ALK translocation, such as the EML4/ALK fusion gene, are considered good prognostic and predictive biomarkers. Recently, the results from a basket clinical trial, demonstrated that patients harboring EGFR mutations or ALK rearrangements had the longest median survival compared to patients with other genetic abnormalities (including K-Ras mutation) or patients without an actionable mutation (Lopez-Chavez, Thomas et al. 2015). In addition to prognostic role, most EGFR-activating mutations are recognized as predictive biomarkers in response to therapy with EGFR tyrosine kinase inhibitors (EGFR-TKI). Indeed, several studies reported that patient harboring mutation in exons 19 and 21 of EGFR gene treated with the first generation of EGFR-TKI, gefitinib or erlotinib, showed a better PFS compared to conventional treatment with chemotherapy (Maemondo, Inoue et al. 2010, Mitsudomi, Morita et al. 2010, Zhou, Wu et al. 2011, Rosell, Carcereny et al. 2012, Mitsudomi, Suda et al. 2013, Yang, Wu et al. 2015).

Furthermore, patients with exons 19 and 21 EGFR mutation respond to EGFR-TKI treatment better than EGFR wt patients or than patients harboring exon 20 insertion (Boolell, Alamgeer et al. 2015, Kumar, Ernani et al. 2015) However, although the latter mutation represents the third most frequent EGFR mutation in NSCLC patient, it includes more than 100 variants, often showing a response rate to EGFR-TKI similar to those observed in EGFR wt patient (Yasuda, Kobayashi et al. 2012, Oxnard, Lo et al. 2013). Indeed, nowadays, EGFR wt status and some others alterations in EGFR gene, including those exon 20 variants and the acquired mutation T790M in exon 19, are considered as predictive biomarkers of resistance to first and second generation of EGFR-TKI treatment (Kumar, Ernani et al. 2015). Notably, results from phase I/II trials demonstrated clinical efficacy of the third generation EGFR-TKI (i.e. osimertinib, HM61713 and rociletinib) in patients harboring EGFR T790M mutation. Indeed, on the basis of the results from the phase I trial AURA study, osimertinib was the only approved EGFR TKI for patients with metastatic EGFR T790M mutation-positive NSCLC (Wang, Cang et al. 2016). Similarly to EGFR, the presence of ALK gene translocation is a useful predictive biomarker of the efficacy of ALK targeting agents, such as crizotinib, ceritinib and alectinib. Actually, based on the results from different clinical trials, reporting an increase in objective response rate and in PFS in ALK+ patient, crizotinib and ceritinib received the approval by FDA for the treatment of ALK+ NSCLC patient (Camidge, Bang et al. 2012, El-Osta and Shackelford 2015). While the presence of KRAS mutation is generally accepted as negative prognostic markers, as highlighted from the results of different studies, more complexed is the identification of this alteration as predictive biomarker, also because no direct inhibitor of KRAS have been approved in clinical practice (Zhang, Park et al. 2016). Nonetheless, since KRAS molecule is downstream to EGFR-mediated pathway, epidemiologic studies suggested that the genetic mutation in KRAS gene could be considered as potential negative predictive biomarker to EGFR-TKI. However, evidences from different meta-analyses demonstrated that the supposed negative association between KRAS mutation and EGFR-TKI treatment is not so conclusive (Kumar, Ernani et al. 2015). Indeed, results from a meta-analysis, including 22 studies performed on NSCLC patients, revealed no differences in term of ORR and OS between the KRAS mutant/EGFR wild-type and

KRAS wild-type/EGFR wild-type NSCLC patients, suggesting that the presence of KRAS mutations to predict the sensitivity of NSCLC patients to EGFR-TKI treatment is not useful (Mao, Qiu et al. 2010). Similarly, results derived from the SATURN study, a phase III, randomized and large prospective biomarker study, performed in unresectable NSCLC, which demonstrated that no other than EGFR-mutation can predict the sensitivity to erlotinib (Brugger, Triller et al. 2011). Similarly, the role of K-Ras mutation as predictive biomarker to dictate the response to chemotherapy is also controversial. Indeed, two different studies performed on a small cohort of NSCLC mutant patients showed that KRAS mutation, can predict the resistance to platinum-based doublet chemotherapy as well as chemo-radiotherapy (Yagishita, Horinouchi et al. 2015, Zhou, Dai et al. 2016). Moreover, it has been reported also that the resistance to platinum-based doublet chemotherapy is strongly increased in patient in which KRAS mutation is associated with low tumor expression of BRCA1 and TYMS (Zhou, Dai et al. 2016). Conversely, a retrospective multicentre analysis performed on K-Ras mutant NSCLC patients, treated with first-line platinumcontaining chemotherapy, revealed no correlation between K-Ras mutation and response to chemotherapy (Mellema, Dingemans et al. 2013). Similar results were reported from both the TRIBUTE trial and the

Eastern Cooperative Oncology Group (ECOG) study, reporting that

KRAS mutation was neither prognostic of survival nor predictive of a differential benefit from chemotherapy (Wood, Hensing et al. 2016). Finally, also the rare genetic mutations of ROS1, MET, RET, BRAF and Her2 genes, have been currently used as predictive biomarkers (Kumar, Ernani et al. 2015). For example, since the significant homology between ROS1, a tyrosine-kinase receptor, and ALK, patients carrying ROS1 alteration are currently treated with the ALK inhibitor crizotinib. However, most patients, after an initial response, acquired a secondary mutation G2032R, which mediated crizotinib resistance (Awad, Engelman et al. 2013, Shaw, Ou et al. 2014). Overall, as mentioned above, genomic profiling has created the foundations on which modern personalized chemotherapy is based. Targeted treatment was conceived at first as an histology-based drug regimen, a concept generated by the finding of a fundamental distinction between adenocarcinomas and the epidermoid histotype in terms of specific drug response. In

time, the attention of the investigators focused on the former histotype and on the demonstration of a malignant transformation as a sequence of genetic anomalies leading to increasing biological, phenotypic aggressiveness. The era of the so-called oncogenic addiction had started which revealed that, in a limited group of patients according mainly to their ethnicity, a restricted series of genetic aberrations (ie, EGFR, ALK, ROS1) could be targeted with specific pharmacologic agents characterized by an unprecedented, albeit not curative, efficacy (Shea, Costa et al. 2016). As a consequence, multiple prognostic tools are available based on the current knowledge of predominant biomarkers, the actual clinical value of which is, at best, uncertain. In addition, the multiplication of druggable genetic targets has made the number of active agents available in the clinical practice equally remarkably increasing – and with them the escalating costs of treatment. The evolution of personalized medicine had become unstoppable and a further leap forward consisted in the focus on the steps of the widely studied oncogenic pathways according to the sequence “Each step – a drug”. The expression of oncogenic pathways has been related to outcomes in patients with NSCLC, giving clinicians a unique opportunity to add genetic assessment to the other predictors of outcome after lung cancer management. Also, the concept of tumor multiclonality has made necessary a further evolution (Mitsudomi, Suda et al. 2013). In fact, genomic sequencing has rendered this evolution theoretically straightforward, albeit several practical hurdles still intervene between the lab and a more widespread use of Next Generation Sequencing in the clinical practice. However, the likelihood of identifying a thorough genetic map for each individual in order to treat current diseases but also to predict the onset of others has become a reality and the actual foundation on which the modern concept of personalized medicine is based. More recently, regulatory substances indirectly related to genomic coding, such as miRNA, have attracted attention as potential druggable targets and their relation with epigenetic processes thought to activate metastatic dissemination, like epithelial to mesenchymal transition (EMT), are being extensively investigated (Chen, Gibbons et al. 2014, Sin, Wang et al. 2016). The general picture we can observe is that of the patient as a complex, multifaceted structure where genotype and phenotype interact to offer an ever-changing profile of molecular targets and attendant biological expressions. This profile is specific and designed to resist countermeasures

via the activation of alternative pathways still partially undiscovered. Last but not least, immunotherapy has experienced a renewed interest for solid tumors, including lung cancer, thanks to advances in the understanding of immune evasion strategies used by tumors, development of new immunotherapies and positive results with checkpoints inhibitors in randomized clinical trials. In particular, nivolumab and pembrolizumab improved overall survival compared with docetaxel as second line therapy of patients with non-small-cell lung cancer pretreated with platinum based chemotherapy and they represent now a new, powerful weapon, improving the outlook for lung cancer patients (Borghaei, Paz-Ares et al. 2015, Brahmer, Reckamp et al. 2015, Herbst, Baas et al. 2015, Fehrenbacher, Spira et al. 2016) (Table 1). Many questions remain to be addressed on immunotherapy, regarding the predictive role of PDL-1 expression, the efficacy of checkpoint inhibitors in other setting (adjuvant, locally advanced disease), the optimal schedule of treatment (as single agents or in combination with chemotherapy, biologic therapy, radiotherapy). On these bases, in the last years the therapeutic algorithm of lung cancer has become much more complex and articulated, with different kinds of drugs, including chemotherapy (with pemetrexed or bevacizumab based regimens for non-squamous histology), targeted-based agents (gefitinib erlotinib, afatinib, osimertinib), angiogenesis inhibitors (bevacizumab, nintedanib, ramucirumab) and immunotherapy (nivolumab, pembrolizumab), and multiple lines of treatments, for patients with squamous and non-squamous hystology, EGFR mutation and ALK rearrangement (Figure 1). A further challenge is represented by re-biopsy, required to evaluate the molecular pattern of lung cancer at progression, with the aim to use targeted based agents of new generation, such as third generation tyrosine kinase inhibitors or second generation ALK inhibitors. The growing diagnostic challenges and the new exciting therapeutic opportunities highlight the need of a multidisciplinary approach, necessary for a proper management of lung cancer patients in the era of personalized medicine.

References

Awad, M. M., J. A. Engelman and A. T. Shaw (2013). "Acquired resistance to crizotinib from a mutation in CD74-ROS1." N Engl J Med 369(12): 1173. Boolell, V., M. Alamgeer, D. N. Watkins and V. Ganju (2015). "The Evolution of Therapies in Non-Small Cell Lung Cancer." Cancers (Basel) 7(3): 1815-1846. Borghaei, H., L. Paz-Ares, L. Horn, D. R. Spigel, M. Steins, N. E. Ready, L. Q. Chow, E. E. Vokes, E. Felip, E. Holgado, F. Barlesi, M. Kohlhaufl, O. Arrieta, M. A. Burgio, J. Fayette, H. Lena, E. Poddubskaya, D. E. Gerber, S. N. Gettinger, C. M. Rudin, N. Rizvi, L. Crino, G. R. Blumenschein, Jr., S. J. Antonia, C. Dorange, C. T. Harbison, F. Graf Finckenstein and J. R. Brahmer (2015). "Nivolumab versus Docetaxel in Advanced Nonsquamous Non-Small-Cell Lung Cancer." N Engl J Med 373(17): 1627-1639. Brahmer, J., K. L. Reckamp, P. Baas, L. Crino, W. E. Eberhardt, E. Poddubskaya, S. Antonia, A. Pluzanski, E. E. Vokes, E. Holgado, D. Waterhouse, N. Ready, J. Gainor, O. Aren Frontera, L. Havel, M. Steins, M. C. Garassino, J. G. Aerts, M. Domine, L. Paz-Ares, M. Reck, C. Baudelet, C. T. Harbison, B. Lestini and D. R. Spigel (2015). "Nivolumab versus Docetaxel in Advanced Squamous-Cell Non-Small-Cell Lung Cancer." N Engl J Med 373(2): 123-135. Brugger, W., N. Triller, M. Blasinska-Morawiec, S. Curescu, R. Sakalauskas, G. M. Manikhas, J. Mazieres, R. Whittom, C. Ward, K. Mayne, K. Trunzer and F. Cappuzzo (2011). "Prospective molecular marker analyses of EGFR and KRAS from a randomized, placebo-controlled study of erlotinib maintenance therapy in advanced non-small-cell lung cancer." J Clin Oncol 29(31): 4113-4120. Brunelli, A., A. Charloux, C. T. Bolliger, G. Rocco, J. P. Sculier, G. Varela, M. Licker, M. K. Ferguson, C. Faivre-Finn, R. M. Huber, E. M. Clini, T. Win, D. De Ruysscher, L. Goldman, S. European Respiratory and t. European Society of Thoracic Surgeons joint task force on fitness for radical (2009). "ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)." Eur Respir J 34(1): 17-41. Buckler, A. J., J. L. Mulshine, R. Gottlieb, B. Zhao, P. D. Mozley and L. Schwartz (2010). "The use of volumetric CT as an imaging biomarker in lung cancer." Acad Radiol 17(1): 100-106. Camidge, D. R., Y. J. Bang, E. L. Kwak, A. J. Iafrate, M. Varella-Garcia, S. B. Fox, G. J. Riely, B. Solomon, S. H. Ou, D. W. Kim, R. Salgia, P. Fidias, J. A. Engelman, L. Gandhi, P. A. Janne, D. B. Costa, G. I. Shapiro, P. Lorusso, K. Ruffner, P. Stephenson, Y. Tang, K. Wilner, J. W. Clark and A. T. Shaw (2012). "Activity and safety of crizotinib in patients with ALK-positive non-small-cell lung cancer: updated results from a phase 1 study." Lancet Oncol 13(10): 1011-1019. Cassidy, A., J. P. Myles, M. van Tongeren, R. D. Page, T. Liloglou, S. W. Duffy and J. K. Field (2008). "The LLP risk model: an individual risk prediction model for lung cancer." Br J Cancer 98(2): 270-276. Chang, J. Y., S. Senan, M. A. Paul, R. J. Mehran, A. V. Louie, P. Balter, H. J. Groen, S. E. McRae, J. Widder, L. Feng, B. E. van den Borne, M. F. Munsell, C. Hurkmans, D. A. Berry, E. van Werkhoven, J. J. Kresl, A. M. Dingemans, O. Dawood, C. J. Haasbeek, L. S. Carpenter, K. De Jaeger, R. Komaki, B. J. Slotman, E. F. Smit and J. A. Roth (2015). "Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials." Lancet Oncol 16(6): 630-637. Chatziandreou, I., P. Tsioli, S. Sakellariou, I. Mourkioti, I. Giannopoulou, G. Levidou, P. Korkolopoulou, E. Patsouris and A. A. Saetta (2015). "Comprehensive Molecular Analysis of NSCLC; Clinicopathological Associations." PLoS One 10(7): e0133859. Chen, L., D. L. Gibbons, S. Goswami, M. A. Cortez, Y. H. Ahn, L. A. Byers, X. Zhang, X. Yi, D. Dwyer, W. Lin, L. Diao, J. Wang, J. D. Roybal, M. Patel, C. Ungewiss, D. Peng, S. Antonia, M. MediavillaVarela, G. Robertson, S. Jones, M. Suraokar, J. W. Welsh, B. Erez, Wistuba, II, L. Chen, D. Peng, S. Wang, S. E. Ullrich, J. V. Heymach, J. M. Kurie and F. X. Qin (2014). "Metastasis is regulated via

microRNA-200/ZEB1 axis control of tumour cell PD-L1 expression and intratumoral immunosuppression." Nat Commun 5: 5241. de Koning, H. J., R. Meza, S. K. Plevritis, K. ten Haaf, V. N. Munshi, J. Jeon, S. A. Erdogan, C. Y. Kong, S. S. Han, J. van Rosmalen, S. E. Choi, P. F. Pinsky, A. Berrington de Gonzalez, C. D. Berg, W. C. Black, M. C. Tammemagi, W. D. Hazelton, E. J. Feuer and P. M. McMahon (2014). "Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force." Ann Intern Med 160(5): 311-320. El-Osta, H. and R. Shackelford (2015). "Personalized treatment options for ALK-positive metastatic non-small-cell lung cancer: potential role for Ceritinib." Pharmgenomics Pers Med 8: 145-154. Fehrenbacher, L., A. Spira, M. Ballinger, M. Kowanetz, J. Vansteenkiste, J. Mazieres, K. Park, D. Smith, A. Artal-Cortes, C. Lewanski, F. Braiteh, D. Waterkamp, P. He, W. Zou, D. S. Chen, J. Yi, A. Sandler, A. Rittmeyer and P. S. Group (2016). "Atezolizumab versus docetaxel for patients with previously treated non-small-cell lung cancer (POPLAR): a multicentre, open-label, phase 2 randomised controlled trial." Lancet. Field, J. K., M. Oudkerk, J. H. Pedersen and S. W. Duffy (2013). "Prospects for population screening and diagnosis of lung cancer." Lancet 382(9893): 732-741. Gonzalez-Rivas, D., H. Aymerich, C. Bonome and E. Fieira (2015). "From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient." Ann Thorac Surg 100(6): 2003-2005. Gonzalez-Rivas, D., C. Bonome, E. Fieira, H. Aymerich, R. Fernandez, M. Delgado, L. Mendez and M. de la Torre (2016). "Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?" Eur J Cardiothorac Surg 49(3): 721-731. Herbst, R. S., P. Baas, D. W. Kim, E. Felip, J. L. Perez-Gracia, J. Y. Han, J. Molina, J. H. Kim, C. D. Arvis, M. J. Ahn, M. Majem, M. J. Fidler, G. de Castro, Jr., M. Garrido, G. M. Lubiniecki, Y. Shentu, E. Im, M. Dolled-Filhart and E. B. Garon (2015). "Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial." Lancet. Hinshaw, J. L., M. G. Lubner, T. J. Ziemlewicz, F. T. Lee, Jr. and C. L. Brace (2014). "Percutaneous tumor ablation tools: microwave, radiofrequency, or cryoablation--what should you use and why?" Radiographics 34(5): 1344-1362. Klapper, J. and T. A. D'Amico (2015). "VATS versus open surgery for lung cancer resection: moving toward a minimally invasive approach." J Natl Compr Canc Netw 13(2): 162-164. Kumar, M., V. Ernani and T. K. Owonikoko (2015). "Biomarkers and targeted systemic therapies in advanced non-small cell lung cancer." Mol Aspects Med 45: 55-66. Langer, C. J., B. Besse, A. Gualberto, E. Brambilla and J. C. Soria (2010). "The evolving role of histology in the management of advanced non-small-cell lung cancer." J Clin Oncol 28(36): 5311-5320. Lee, T., B. Lee, Y. L. Choi, J. Han, M. J. Ahn and S. W. Um (2016). "Non-small Cell Lung Cancer with Concomitant EGFR, KRAS, and ALK Mutation: Clinicopathologic Features of 12 Cases." J Pathol Transl Med 50(3): 197-203. Lemjabbar-Alaoui, H., O. U. Hassan, Y. W. Yang and P. Buchanan (2015). "Lung cancer: Biology and treatment options." Biochim Biophys Acta 1856(2): 189-210. Lopez-Chavez, A., A. Thomas, A. Rajan, M. Raffeld, B. Morrow, R. Kelly, C. A. Carter, U. Guha, K. Killian, C. C. Lau, Z. Abdullaev, L. Xi, S. Pack, P. S. Meltzer, C. L. Corless, A. Sandler, C. Beadling, A. Warrick, D. J. Liewehr, S. M. Steinberg, A. Berman, A. Doyle, E. Szabo, Y. Wang and G. Giaccone (2015). "Molecular profiling and targeted therapy for advanced thoracic malignancies: a biomarker-derived, multiarm, multihistology phase II basket trial." J Clin Oncol 33(9): 1000-1007.

Maemondo, M., A. Inoue, K. Kobayashi, S. Sugawara, S. Oizumi, H. Isobe, A. Gemma, M. Harada, H. Yoshizawa, I. Kinoshita, Y. Fujita, S. Okinaga, H. Hirano, K. Yoshimori, T. Harada, T. Ogura, M. Ando, H. Miyazawa, T. Tanaka, Y. Saijo, K. Hagiwara, S. Morita, T. Nukiwa and G. North-East Japan Study (2010). "Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR." N Engl J Med 362(25): 2380-2388. Mahar, A. L., C. Compton, L. M. McShane, S. Halabi, H. Asamura, R. Rami-Porta, P. A. Groome and C. Molecular Modellers Working Group of American Joint Committee on (2015). "Refining Prognosis in Lung Cancer: A Report on the Quality and Relevance of Clinical Prognostic Tools." J Thorac Oncol 10(11): 1576-1589. Mao, C., L. X. Qiu, R. Y. Liao, F. B. Du, H. Ding, W. C. Yang, J. Li and Q. Chen (2010). "KRAS mutations and resistance to EGFR-TKIs treatment in patients with non-small cell lung cancer: a meta-analysis of 22 studies." Lung Cancer 69(3): 272-278. Mellema, W. W., A. M. Dingemans, E. Thunnissen, P. J. Snijders, J. Derks, D. A. Heideman, R. Van Suylen and E. F. Smit (2013). "KRAS mutations in advanced nonsquamous non-small-cell lung cancer patients treated with first-line platinum-based chemotherapy have no predictive value." J Thorac Oncol 8(9): 1190-1195. Mitsudomi, T., S. Morita, Y. Yatabe, S. Negoro, I. Okamoto, J. Tsurutani, T. Seto, M. Satouchi, H. Tada, T. Hirashima, K. Asami, N. Katakami, M. Takada, H. Yoshioka, K. Shibata, S. Kudoh, E. Shimizu, H. Saito, S. Toyooka, K. Nakagawa, M. Fukuoka and G. West Japan Oncology (2010). "Gefitinib versus cisplatin plus docetaxel in patients with non-small-cell lung cancer harbouring mutations of the epidermal growth factor receptor (WJTOG3405): an open label, randomised phase 3 trial." Lancet Oncol 11(2): 121-128. Mitsudomi, T., K. Suda and Y. Yatabe (2013). "Surgery for NSCLC in the era of personalized medicine." Nat Rev Clin Oncol 10(4): 235-244. Moyer, V. A. and U. S. P. S. T. Force (2014). "Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement." Ann Intern Med 160(5): 330-338. National Lung Screening Trial Research, T., D. R. Aberle, A. M. Adams, C. D. Berg, W. C. Black, J. D. Clapp, R. M. Fagerstrom, I. F. Gareen, C. Gatsonis, P. M. Marcus and J. D. Sicks (2011). "Reduced lung-cancer mortality with low-dose computed tomographic screening." N Engl J Med 365(5): 395-409. Ng, C. S., S. C. Yu, R. W. Lau and A. P. Yim (2016). "Hybrid DynaCT-guided electromagnetic navigational bronchoscopic biopsydagger." Eur J Cardiothorac Surg 49 Suppl 1: i87-i88. Novello, S., H. Asamura, J. Bazan, D. Carbone, P. Goldstraw, D. Grunenwald, U. Ricardi and J. Vansteenkiste (2014). "Early stage lung cancer: progress in the last 40 years [corrected]." J Thorac Oncol 9(10): 1434-1442. Opitz, I., G. Rocco, A. Brunelli, G. Varela, G. Massard, W. Weder and S. European Society of Thoracic (2015). "Surgery versus SABR for resectable non-small-cell lung cancer." Lancet Oncol 16(8): e372-373. Oxnard, G. R., P. C. Lo, M. Nishino, S. E. Dahlberg, N. I. Lindeman, M. Butaney, D. M. Jackman, B. E. Johnson and P. A. Janne (2013). "Natural history and molecular characteristics of lung cancers harboring EGFR exon 20 insertions." J Thorac Oncol 8(2): 179-184. Paul, S., N. K. Altorki, S. Sheng, P. C. Lee, D. H. Harpole, M. W. Onaitis, B. M. Stiles, J. L. Port and T. A. D'Amico (2010). "Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database." J Thorac Cardiovasc Surg 139(2): 366-378. Perez-Moreno, P., E. Brambilla, R. Thomas and J. C. Soria (2012). "Squamous cell carcinoma of the lung: molecular subtypes and therapeutic opportunities." Clin Cancer Res 18(9): 24432451. Puri, V., T. D. Crabtree, J. M. Bell, S. R. Broderick, D. Morgensztern, G. A. Colditz, D. Kreisel, A. S. Krupnick, G. A. Patterson, B. F. Meyers, A. Patel and C. G. Robinson (2015). "Treatment

Outcomes in Stage I Lung Cancer: A Comparison of Surgery and Stereotactic Body Radiation Therapy." J Thorac Oncol 10(12): 1776-1784. Raji, O. Y., S. W. Duffy, O. F. Agbaje, S. G. Baker, D. C. Christiani, A. Cassidy and J. K. Field (2012). "Predictive accuracy of the Liverpool Lung Project risk model for stratifying patients for computed tomography screening for lung cancer: a case-control and cohort validation study." Ann Intern Med 157(4): 242-250. Rocco, G. (2016). "Non-intubated uniportal lung surgerydagger." Eur J Cardiothorac Surg 49 Suppl 1: i3-i5. Rocco, G., M. S. Allen, N. K. Altorki, H. Asamura, M. G. Blum, F. C. Detterbeck, C. M. Dresler, D. Gossot, S. C. Grondin, M. T. Jaklitsch, J. D. Mitchell, J. R. Newton, Jr., P. E. Van Schil, T. K. Waddell and D. E. Wood (2013). "Clinical statement on the role of the surgeon and surgical issues relating to computed tomography screening programs for lung cancer." Ann Thorac Surg 96(1): 357-360. Rocco, G., N. Martucci, C. La Manna, D. R. Jones, G. De Luca, A. La Rocca, A. Cuomo and R. Accardo (2013). "Ten-year experience on 644 patients undergoing single-port (uniportal) video-assisted thoracoscopic surgery." Ann Thorac Surg 96(2): 434-438. Rocco, R., R. A. Incalzi, G. Pennazza, M. Santonico, C. Pedone, I. R. Bartoli, C. Vernile, G. Mangiameli, A. La Rocca, G. De Luca, G. Rocco and P. Crucitti (2015). "BIONOTE e-nose technology may reduce false positives in lung cancer screening programmesdagger." Eur J Cardiothorac Surg. Rosell, R., E. Carcereny, R. Gervais, A. Vergnenegre, B. Massuti, E. Felip, R. Palmero, R. GarciaGomez, C. Pallares, J. M. Sanchez, R. Porta, M. Cobo, P. Garrido, F. Longo, T. Moran, A. Insa, F. De Marinis, R. Corre, I. Bover, A. Illiano, E. Dansin, J. de Castro, M. Milella, N. Reguart, G. Altavilla, U. Jimenez, M. Provencio, M. A. Moreno, J. Terrasa, J. Munoz-Langa, J. Valdivia, D. Isla, M. Domine, O. Molinier, J. Mazieres, N. Baize, R. Garcia-Campelo, G. Robinet, D. Rodriguez-Abreu, G. Lopez-Vivanco, V. Gebbia, L. Ferrera-Delgado, P. Bombaron, R. Bernabe, A. Bearz, A. Artal, E. Cortesi, C. Rolfo, M. Sanchez-Ronco, A. Drozdowskyj, C. Queralt, I. de Aguirre, J. L. Ramirez, J. J. Sanchez, M. A. Molina, M. Taron, L. Paz-Ares, P.-C. Spanish Lung Cancer Group in collaboration with Groupe Francais de and T. Associazione Italiana Oncologia (2012). "Erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFR mutation-positive non-small-cell lung cancer (EURTAC): a multicentre, open-label, randomised phase 3 trial." Lancet Oncol 13(3): 239-246. Salati, M., A. Brunelli, F. Xiume, M. Refai, C. Pompili and A. Sabbatini (2012). "Does fasttracking increase the readmission rate after pulmonary resection? A case-matched study." Eur J Cardiothorac Surg 41(5): 1083-1087; discussion 1087. Senan, S., M. A. Paul and F. J. Lagerwaard (2013). "Treatment of early-stage lung cancer detected by screening: surgery or stereotactic ablative radiotherapy?" Lancet Oncol 14(7): e270-274. Shamji, F. M. and J. Deslauriers (2013). "Fast-tracking investigation and staging of patients with lung cancer." Thorac Surg Clin 23(2): 187-191. Shaw, A. T., S. H. Ou, Y. J. Bang, D. R. Camidge, B. J. Solomon, R. Salgia, G. J. Riely, M. VarellaGarcia, G. I. Shapiro, D. B. Costa, R. C. Doebele, L. P. Le, Z. Zheng, W. Tan, P. Stephenson, S. M. Shreeve, L. M. Tye, J. G. Christensen, K. D. Wilner, J. W. Clark and A. J. Iafrate (2014). "Crizotinib in ROS1-rearranged non-small-cell lung cancer." N Engl J Med 371(21): 1963-1971. Shea, M., D. B. Costa and D. Rangachari (2016). "Management of advanced non-small cell lung cancers with known mutations or rearrangements: latest evidence and treatment approaches." Ther Adv Respir Dis 10(2): 113-129. Siegel, R. L., K. D. Miller and A. Jemal (2016). "Cancer statistics, 2016." CA Cancer J Clin 66(1): 7-30.

Sin, T. K., F. Wang, F. Meng, S. C. Wong, W. C. Cho, P. M. Siu, L. W. Chan and B. Y. Yung (2016). "Implications of MicroRNAs in the Treatment of Gefitinib-Resistant Non-Small Cell Lung Cancer." Int J Mol Sci 17(2). Smith, S. L. and P. E. Jennings (2015). "Lung radiofrequency and microwave ablation: a review of indications, techniques and post-procedural imaging appearances." Br J Radiol 88(1046): 20140598. Sozzi, G., M. Boeri, M. Rossi, C. Verri, P. Suatoni, F. Bravi, L. Roz, D. Conte, M. Grassi, N. Sverzellati, A. Marchiano, E. Negri, C. La Vecchia and U. Pastorino (2014). "Clinical utility of a plasma-based miRNA signature classifier within computed tomography lung cancer screening: a correlative MILD trial study." J Clin Oncol 32(8): 768-773. Tammemagi, M. C., H. A. Katki, W. G. Hocking, T. R. Church, N. Caporaso, P. A. Kvale, A. K. Chaturvedi, G. A. Silvestri, T. L. Riley, J. Commins and C. D. Berg (2013). "Selection criteria for lung-cancer screening." N Engl J Med 368(8): 728-736. Tang, H. and J. B. Shrager (2016). "CRISPR/Cas-mediated genome editing to treat EGFRmutant lung cancer: a personalized molecular surgical therapy." EMBO Mol Med 8(2): 83-85. Tiseo, M., F. Gelsomino, D. Boggiani, B. Bortesi, M. Bartolotti, C. Bozzetti, G. Sammarelli, E. Thai and A. Ardizzoni (2011). "EGFR and EML4-ALK gene mutations in NSCLC: a case report of erlotinib-resistant patient with both concomitant mutations." Lung Cancer 71(2): 241-243. Travis, W. D., E. Brambilla, M. Noguchi, A. G. Nicholson, K. R. Geisinger, Y. Yatabe, D. G. Beer, C. A. Powell, G. J. Riely, P. E. Van Schil, K. Garg, J. H. Austin, H. Asamura, V. W. Rusch, F. R. Hirsch, G. Scagliotti, T. Mitsudomi, R. M. Huber, Y. Ishikawa, J. Jett, M. Sanchez-Cespedes, J. P. Sculier, T. Takahashi, M. Tsuboi, J. Vansteenkiste, I. Wistuba, P. C. Yang, D. Aberle, C. Brambilla, D. Flieder, W. Franklin, A. Gazdar, M. Gould, P. Hasleton, D. Henderson, B. Johnson, D. Johnson, K. Kerr, K. Kuriyama, J. S. Lee, V. A. Miller, I. Petersen, V. Roggli, R. Rosell, N. Saijo, E. Thunnissen, M. Tsao and D. Yankelewitz (2011). "International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma." J Thorac Oncol 6(2): 244-285. Trisolini, R., A. Cancellieri, C. Tinelli, D. de Biase, I. Valentini, G. Casadei, D. Paioli, F. Ferrari, G. Gordini, M. Patelli and G. Tallini (2015). "Randomized Trial of Endobronchial UltrasoundGuided Transbronchial Needle Aspiration With and Without Rapid On-site Evaluation for Lung Cancer Genotyping." Chest 148(6): 1430-1437. Wang, S., S. Cang and D. Liu (2016). "Third-generation inhibitors targeting EGFR T790M mutation in advanced non-small cell lung cancer." J Hematol Oncol 9: 34. Won, J. K., B. Keam, J. Koh, H. J. Cho, Y. K. Jeon, T. M. Kim, S. H. Lee, D. S. Lee, D. W. Kim and D. H. Chung (2015). "Concomitant ALK translocation and EGFR mutation in lung cancer: a comparison of direct sequencing and sensitive assays and the impact on responsiveness to tyrosine kinase inhibitor." Ann Oncol 26(2): 348-354. Wood, K., T. Hensing, R. Malik and R. Salgia (2016). "Prognostic and Predictive Value in KRAS in Non-Small-Cell Lung Cancer: A Review." JAMA Oncol 2(6): 805-812. Xie, D., H. Wang, K. Fei, C. Chen, D. Zhao, X. Zhou, B. Xie, L. Jiang, Q. Chen, N. Song, J. Dai, G. Jiang and Y. Zhu (2016). "Single-port video-assisted thoracic surgery in 1063 cases: a singleinstitution experiencedagger." Eur J Cardiothorac Surg 49 Suppl 1: i31-i36. Yagishita, S., H. Horinouchi, K. S. Sunami, S. Kanda, Y. Fujiwara, H. Nokihara, N. Yamamoto, M. Sumi, K. Shiraishi, T. Kohno, K. Furuta, K. Tsuta, T. Tamura and Y. Ohe (2015). "Impact of KRAS mutation on response and outcome of patients with stage III non-squamous non-small cell lung cancer." Cancer Sci 106(10): 1402-1407. Yang, J. C., Y. L. Wu, M. Schuler, M. Sebastian, S. Popat, N. Yamamoto, C. Zhou, C. P. Hu, K. O'Byrne, J. Feng, S. Lu, Y. Huang, S. L. Geater, K. Y. Lee, C. M. Tsai, V. Gorbunova, V. Hirsh, J. Bennouna, S. Orlov, T. Mok, M. Boyer, W. C. Su, K. H. Lee, T. Kato, D. Massey, M. Shahidi, V. Zazulina and L. V. Sequist (2015). "Afatinib versus cisplatin-based chemotherapy for EGFR

mutation-positive lung adenocarcinoma (LUX-Lung 3 and LUX-Lung 6): analysis of overall survival data from two randomised, phase 3 trials." Lancet Oncol 16(2): 141-151. Yasuda, H., S. Kobayashi and D. B. Costa (2012). "EGFR exon 20 insertion mutations in nonsmall-cell lung cancer: preclinical data and clinical implications." Lancet Oncol 13(1): e23-31. Zhang, J., D. Park, D. M. Shin and X. Deng (2016). "Targeting KRAS-mutant non-small cell lung cancer: challenges and opportunities." Acta Biochim Biophys Sin (Shanghai) 48(1): 11-16. Zheng, A., X. Wang, X. Yang, W. Wang, G. Huang, Y. Gai and X. Ye (2014). "Major complications after lung microwave ablation: a single-center experience on 204 sessions." Ann Thorac Surg 98(1): 243-248. Zhou, C., Y. L. Wu, G. Chen, J. Feng, X. Q. Liu, C. Wang, S. Zhang, J. Wang, S. Zhou, S. Ren, S. Lu, L. Zhang, C. Hu, C. Hu, Y. Luo, L. Chen, M. Ye, J. Huang, X. Zhi, Y. Zhang, Q. Xiu, J. Ma, L. Zhang and C. You (2011). "Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): a multicentre, open-label, randomised, phase 3 study." Lancet Oncol 12(8): 735-742. Zhou, H., Y. Dai, L. Zhu, C. Wang, X. Fei, Q. Pan, J. Chen, X. Shi, Y. Yang, X. Tao and P. Shi (2016). "Poor response to platinum-based chemotherapy is associated with KRAS mutation and concomitant low expression of BRAC1 and TYMS in NSCLC." J Int Med Res 44(1): 89-98.

Figure Legends Figure 1. Therapeutic algorithm for advanced NSCLC Chemotherapy, targeted-based agents, angiogenesis inhibitors and immunotherapy, and multiple lines of treatments, for patients with squamous and non-squamous hystology, EGFR mutation and ALK rearrangement.

Advanced NSCLC EGFR mutated

First line

Afatinib, Erlotinib, Gefitinib,

Squamous hystotype

Platinum-based (no pemetrexed or bevacizumab)

Non-squamous hystotipe

Platinum/Pemetrexed Carbo+Tax+Bevacizumab

ALK rearranged

Crizotinib

Maintenance

Second line

Osimertinib for T790M +

Third line

Chemotherapy

Docetaxel ± ramucirumab Nivolumab, Pembrolizumab (PDL-1), erlotinib

Erlotinib

Pemetrexed, Docetaxel ± Nintedanib/ramucirumab Nivolumab, Pembrolizumab (PDL-1), erlotinib Erlotinib

Ceritinib Alectinib Chemotherapy

Table 1. Randomized clinical trials with checkpoint inhibitors in lung cancer. Study

Author

CheckMate 017

(Brahmer, Reckamp et al. 2015)

CheckMate 057

(Borghaei, PazAres et al. 2015)

POPLAR

(Fehrenbacher, Spira et al. 2016)

KEYNOTE 010

(Herbst, Baas et al. 2015)

° p=n.s; *p=0.0008; **p<0.0001

Phase

Treatment

III

Nivolumab vs docetaxel, squamous

III

Nivolumab vs docetaxel, non-squamous

II

Atezolizumab vs docetaxel

III

Pembrolizumab 2 vs pembrolizumab 10 vs docetaxel

Pts

RR, (%)

PFS, (months)

OS, (months)

272

20 vs 9, p=0.008

3.5 vs 2.8, p<0.001

9.2 vs 6.0, HR: 0.59, p<0.001

582

19 vs 12, p=0.02

2.3 vs 4.2, p=0.39

12.2 vs 9.4, HR: 0.73, p=0.0015

287

15 vs 15

2.8 vs 3.4

11.4 vs 9.5, HR: 0.77, p=0.11

1034

18% (.0005) 18% (.00002) vs 9%

3.9 (HR 0.88)° vs 4.0 (HR0.79)° vs 4.0

10.4 (HR 0.71)* 12.7(HR 0.61)** vs 8.5