Faculty Bibliography

In this article, we summarize the progress made in lung cancer, mesothelioma, and thymic epithelial malignancy during the period 2005-2025. We enlisted multidisciplinary thoracic oncologic experts to tackle this task. The main focus of the article concerns how basic science with translational impact has improved the diagnosis, prognosis, and therapy of these cancers. During the past 20 years, we have come to the realization that "lung cancer" is a name that encompasses tumors with vast histologic, immune, and genomic differences that in turn influence prognosis and response to therapy. For example, programmed death-ligand 1 levels are being used as an immune signature which guides the use of immunotherapy. There is an 85% higher risk for developing lung cancer among first-degree relatives of patients with lung cancer. Accordingly, an increasing number of lung cancers are being identified in carriers of predisposing germline pathogenic inactivating mutations, suggesting that screening programs for early lung cancer detection may benefit family members. Underscoring the role of genetics, and the importance of germline testing, a different variant of mesothelioma has been identified developing in carriers of inactivating heterozygous germline mutations of BAP1 and of other tumor suppressor genes, including a new variant of mesothelioma caused by fusion genes. These variants of mesothelioma are characterized by specific histologic and molecular genetic alterations. These patients benefit from screening programs as they are at risk of multiple malignancies, their tumors are usually much less aggressive, and they are more responsive to therapy compared with sporadic, asbestos-induced mesotheliomas. Thus, the tailored therapeutic approach that is described here for lung cancer may extend to patients with mesothelioma, rather than the previous "one therapy fits all" approach. Progress in the rare thymic epithelial tumors has been less marked; however, recent insights into the biology of thymic tumors have resulted in the development of clinically relevant interventions.

BACKGROUND:Porcine genome editing has revolutionized xenotransplantation, recently enabling the first pig-to-human heart xenotransplants. However, the xeno-immune response in heart xenografts remains largely unexplored. This study aimed to precisely characterize the xeno-immune response and injury in two heart xenografts, transplanted from 10-gene-edited pigs into brain-dead human recipients. METHODS:We analyzed xenograft biopsies at 66-hour post-reperfusion using a multimodal phenotyping approach combining: morphological evaluation, immunophenotyping, ultrastructural assessment, automated quantification of multiplex immunofluorescence staining and gene expression profiling. Xenografts before implantation and wild-type pig hearts with and without ischemia reperfusion injury and brain death were used as controls. RESULTS:Both xenografts showed evidence of endothelial activation and mild microvascular inflammation without capillary C4d deposition. Immune infiltrates were mainly composed of CD15+ and CD68+ innate immune cells. Ultrastructural assessment showed endothelial swelling with occasional intravascular leucocytes. Deep-learning based automated multiplex immunofluorescence analysis confirmed that microvascular inflammation was primarily associated with CD15+ and CD68+ innate immune cells. Both xenografts showed increased expression of genes and pathways associated with monocyte/macrophage activation, neutrophil activation, interferon-gamma response, natural killer cell burden, endothelial activation, apoptosis and injury repair. This phenotype was absent in all control pig hearts, independently from ischemia reperfusion injury and brain death. CONCLUSIONS:Multimodal phenotyping of pig-to-human heart xenografts revealed early signs of xeno-immune response, characterized by mild innate microvascular inflammation, endothelial activation, and molecular signature characteristic of antibody-mediated rejection. Developing such precision diagnostic system could improve graft monitoring in future clinical settings.

Xenotransplantation of genetically-modified pig kidneys offers a solution to the scarcity of organs for end-stage renal disease patients.¹ We performed a 61-day alpha-Gal knock-out pig kidney and thymic autograft transplant into a nephrectomized brain-dead human using clinically approved immunosuppression, without CD40 blockade or additional genetic modification. Hemodynamic and electrolyte stability and dialysis independence were achieved. Post-operative day (POD) 10 biopsies revealed glomerular IgM and IgA deposition, activation of early complement components and mesangiolysis with stable renal function without proteinuria, a phenotype not seen in allotransplantation. On POD 33, an abrupt increase in serum creatinine was associated with antibody-mediated rejection and increased donor-specific IgG. Plasma exchange, C3/C3b inhibition and rabbit anti-thymocyte globulin (rATG), completely reversed xenograft rejection. Pre-existing donor-reactive T cell clones expanded progressively in the circulation post-transplant, acquired an effector transcriptional profile and were detected in the POD 33 rejecting xenograft prior to rATG treatment. This study provides the first long-term physiologic, immunologic, and infectious disease monitoring of a pig-to-human kidney xenotransplant and indicates that pre-existing xenoreactive T cells and induced antibodies to unknown epitope(s) present a major challenge, despite significant immunosuppression. It also demonstrates that a minimally gene-edited pig kidney can support long-term life-sustaining physiologic functions in a human.

Indeterminate pulmonary nodules (IPNs), which are nodules that cannot be classified as definitively benign or malignant at the time of detection, are now diagnosed on the order of millions per year. Management of IPNs remains heavily debated, and routine practice ultimately involves some balance of overall clinical risk assessment and additional diagnostic tests or procedures which may generate significant risk, cost, and worry. Biomarkers are biologically based tests or indicators capable of accurately characterizing the physiologic properties of homeostasis and disease that are not otherwise easily evaluated by the clinician. Accurate biomarkers thereby serve as reliable surrogates for biological aberrancy, and importantly for the field of diagnostics, can signal early pathology before it becomes clinically detectable. In the realm of IPNs, biomarker development seeks to address a growing need for noninvasive adjunct tools that can be leveraged clinically to add clarity where diagnostic uncertainty exists. Here, effective diagnostic biomarkers have the potential to hone clinical management, accelerate treatment when indicated, and curb added unnecessary diagnostics. In this review article, the authors highlight the role for biomarkers in the diagnosis of IPNs, outline the methodology for successful biomarker development, and discuss contemporary IPN biomarker research and the remaining challenges and future directions for the field.

INTRODUCTION/UNASSIGNED:Outcomes for NSCLC remain suboptimal. Recent data suggest that cryoablation can generate antitumor immune effects. In this first-in-human phase I clinical trial, we investigated the safety and feasibility of bronchoscopic cryoimmunotherapy (BCI) delivered during standard-of-care bronchoscopy and explored associated systemic immune responses. METHODS/UNASSIGNED:Subjects with known or suspected advanced-stage NSCLC were recruited. BCI was delivered in dose-escalated freeze-thaw cycles to determine maximum dose tolerance. Feasibility assessment was determined with a pre-set goal of achieving successful BCI in more than or equal to 80% of subjects. Safety was assessed by review of BCI-related complications, including grades 2 to 3 bleeding, pneumothorax requiring intervention, and National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 to 5 adverse events. Pre- and post-BCI blood samples were collected to explore changes in the systemic immune profile. RESULTS/UNASSIGNED:Subjects with predominantly clinical TNM stage 3 or 4 adenocarcinoma or squamous cell carcinoma were enrolled. We reached the maximum dose of 30 seconds with 100% feasibility and no BCI-related adverse events. In peripheral blood analysis, we observed a significant decrease in derived neutrophil-to-lymphocyte ratio in the high-dose BCI group in comparison to the low-dose BCI cohort. We also observed increases in inflammatory cytokines-GM-CSF, IFN-γ, IL-1β, IL-17A, and IL-2-and effector memory T cells post-BCI. CONCLUSION/UNASSIGNED:BCI is safe and feasible. In addition, we provide preliminary evidence that at higher dose levels there is a systemic immune response consistent with a cytotoxic profile. Further immune analyses will determine the potential of BCI as an adjunctive therapy in combination with immune checkpoint inhibition in NSCLC treatment.

BACKGROUND:Pleural mesothelioma (PM) is a cancer with a usually dismal prognosis. However, long-term survivors do exist. Herein, we analyzed long-term survivors (>5 years after surgery) from high-volume centers around the world. METHODS:This is a multicenter retrospective descriptive analysis of long-term survivors (overall survival ≥5 years from surgery) treated within a multimodality therapy approach, including macroscopic complete resection. Overall survival was calculated with Kaplan-Meier analysis, and patients were matched by center and surgery year and compared with a control group of short-term survivors (<2 years) in a conditional logistic regression analysis. RESULTS:There were 276 long-term survivors (166 men [63%]), with a median age of 59 years (range 21-83 years) at the time of diagnosis. The histology was epithelioid for 246 patients and nonepithelioid for 30 patients. The disease was on the right side in 58% of the patients. As of this analysis, 148 patients had died, 104 were alive, and 10 were lost to follow-up. Pathologic tumor stages were: pT1 (n = 50), pT2 (n = 63), pT3 (n = 90), or pT4 (n = 16) and pN0 (n = 150), pN1 (n = 20), and pN2 (n = 39). The matched control data set included 333 patients, 95 cases and 238 controls. Comparing short- with long-term survivors, we found moderate evidence that a low white blood cell count before surgery was more often observed in long-term survivors. CONCLUSIONS:The data show that long-term survival in PM is possible in a subgroup of surgically treated patients. Histologic subtype and white blood cell count seem to be prognosticators for longer survival.

How tumor microenvironment shapes lung adenocarcinoma (LUAD) precancer evolution remains poorly understood. Spatial immune profiling of 114 human LUAD and LUAD precursors reveals a progressive increase of adaptive response and a relative decrease of innate immune response as LUAD precursors progress. The immune evasion features align the immune response patterns at various stages. TIM-3-high features are enriched in LUAD precancers, which decrease in later stages. Furthermore, single-cell RNA sequencing (scRNA-seq) and spatial immune and transcriptomics profiling of LUAD and LUAD precursor specimens from 5 mouse models validate high TIM-3 features in LUAD precancers. In vivo TIM-3 blockade at precancer stage, but not at advanced cancer stage, decreases tumor burden. Anti-TIM-3 treatment is associated with enhanced antigen presentation, T cell activation, and increased M1/M2 macrophage ratio. These results highlight the coordination of innate and adaptive immune response/evasion during LUAD precancer evolution and suggest TIM-3 as a potential target for LUAD precancer interception.