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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The treatment paradigm of lung cancer has dramatically changed in recent years with the introduction of immunotherapy&#46; Immune checkpoints inhibitors &#40;ICIs&#41; are antibodies that target the brakes to the effective immune response mediated by CTLA-4 &#40;cytotoxic T-lymphocyte-associated 4&#41; and PD-1 &#40;programmed death 1&#41;&#47;PD-L1 &#40;programmed death ligand-1&#41;&#44; releasing these inhibition points&#46; This mechanism of action enhances T-cell mediated immunity&#44; increasing T cell activation and trafficking to the tumour as well as potentiating the effector functions of the host&#39;s immune system&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">ICIs&#44; particularly the anti-PD-1&#47;PD-L1 have changed the standard treatment for the majority of patients with Non-Small Cell Lung Cancer &#40;NSCLC&#41;&#46; In the metastatic setting&#44; patients currently need to be sub-classified upfront into molecularly distinct groups through genomic testing &#40;<span class="elsevierStyleItalic">EGFR&#44; ALK&#44; ROS1</span>&#41; and need to be analyzed for PD-L1 status by immunohistochemistry&#46; In patients with tumour PD-L1 expression &#8805;50&#37; &#40;approximately 33&#37; of all patients&#41; in the first line setting&#44; the anti-PD-1 agent pembrolizumab is superior to chemotherapy with a platinum doublet&#46; In the phase 3 trial &#40;KEYNOTE 024&#41; pembrolizumab demonstrated an improvement of more than four months for median progression free survival &#40;mPFS&#41; and a 40&#37; risk reduction of death compared to chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently combination strategies &#40;with chemotherapy or two ICIs&#41; have shown very interesting results&#46; The KEYNOTE 189 has demonstrated superiority of platinum-pemetrexed plus pembrolizumab in non-squamous NSCLC in all comers &#40;regardless of PD-L1&#41; with a gain of approximately 4 months in mPFS and potentially increased survival &#40;immature data&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> In the metastatic squamous NSCLC setting &#40;regardless of PD-L1 expression&#41;&#44; the KEYNOTE 407 trial&#44; which compares carboplatin-paclitaxel or nab-paclitaxel with or without pembrolizumab&#44; demonstrated an increase in ORR &#40;58&#46;4&#37; vs 35&#46;0&#37;&#41; and OS of 4&#46;6 months&#44; both results favouring the pembrolizumab containing arm&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Moreover&#44; the combination of anti-CTLA-4 &#40;ipilimumab&#41; and anti-PD-1&#40;nivolumab&#41; has been tested against chemotherapy in the CheckMate 227&#46; In this study&#44; patients were stratified according to tumour mutational burden &#40;TMB&#41; that accounts for the number of non-synonymous mutations per megabase in the tumour &#40;mutations&#47;megabase&#41;&#46; The combination of ipilimumab plus nivolumab in patients with a TMB &#8805;10 &#40;44&#46;2&#37; of all patients evaluated&#41;&#44; achieved a two month increase in mPFS&#44; with a 1-year PFS rate of 42&#46;6&#37; vs 13&#46;2&#37; in the chemotherapy arm&#44; despite the toxicity from the combination which leads to discontinuation of 17&#46;4&#37; compared to 8&#46;9&#37; of patients who received chemotherapy&#46; Importantly&#44; the percentage of patients with response who had an ongoing response after 1 year was 68&#37; with nivolumab plus ipilimumab and 25&#37; with chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The toxicity profile&#44; the availability of tissue and techniques in not all centres to perform TMB could be one of the limitations to the use of this combination&#46; These trials will change the standard treatment in the following months incorporating combination strategies in the first-line setting&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In second-line treatment&#44; after chemotherapy failure&#44; two ICIs &#40;nivolumab&#44; and atezolizumab&#41; have demonstrated superior outcomes in patients when compared to standard chemotherapy with docetaxel regardless of histology or PD-L1 status&#46; Pembrolizumab has shown improved efficacy with the same comparator in patients with PD-L1 &#8805;1&#37;&#46; These are currently approved treatments based on the results of CheckMate 017 and CheckMate 057 for nivolumab&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#44;7</span></a> KEYNOTE 010 for pembrolizumab<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> and OAK trial for atezolizumab&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> All trials showed a clear benefit in Objective Response Rate &#40;ORR&#41; and Overall Survival &#40;OS&#41; with less toxicity compared to docetaxel&#46; Overall&#44; the results were similar between all trials with an ORR around 20&#37; and median OS between 10 and 13 months&#46; Interestingly&#44; in all trials patients with higher PD-L1 expression showed an increased probability of response&#44; although PD-L1 is not a perfect predictive nor prognostic marker in lung cancer&#46; One of the unique and most important results with immunotherapy is the consistent long-term survival queue observed in all trials&#46; The study with the longest follow-up with immunotherapy in lung cancer has reported 16&#37; of patients being alive after 5 years of follow up after stopping treatment &#40;maximum immunotherapy duration of 2 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In locally advanced unresectable patients&#44; where chemoradiotherapy is standard treatment&#44; immunotherapy with the anti-PD-L1 agent durvalumab has also shown benefit&#46; In the PACIFIC trial&#44; patients with stage III NSCLC who did not present a disease progression after platinum-based chemoradiotherapy were randomized to receive durvalumab or placebo during 1 year&#46; A significant benefit in mPFS&#44; of more than 11 months was demonstrated in the durvalumab arm&#44; and with a median time to death or metastasis of 23&#46;2 months with durvalumab Vs 14&#46;6 months with placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> These results have incorporated immunotherapy with ICIs in the locally advanced and metastatic setting of virtually all patients with lung cancer&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Immunotherapy is now being evaluated in earlier stages&#46; A recent report has evaluated the role of neoadjuvant immunotherapy in early stages &#40;I&#44; II and IIIA&#41; for resectable NSCLC&#46; In this small study patients received two cycles of nivolumab before surgery&#46; Results revealed 45&#37; of cases with major pathological response&#44; with a few adverse events and without delay in planned surgery&#46; If confirmed in larger studies&#44; immunotherapy might represent a new tool in the neoadjuvant setting as well&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">ICIs have also been tested in Small-Cell Lung Cancer &#40;SCLC&#41; where systemic treatment has not changed for 30 years&#46; Initial studies tested ipilimumab in combination with chemotherapy in advanced disease and despite the negative results compared with chemotherapy alone&#44; a subgroup of patients presented durable responses and unexpectedly long survival&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the chemoresistant setting&#44; the CheckMate 032&#44; a phase 2 trial&#44; compared nivolumab Vs nivolumab plus ipilimumab in this setting&#46; Encouraging results with nivolumab but particularly from the combination were obtained in this refractory setting with 10&#8211;23&#37; of objective responses&#44; respectively&#46; In a retrospective exploratory analysis&#44; PD-L1 was not a predictive marker for benefit but TMB appeared to select patients who benefited most&#44; particularly from the ipilimumab and nivolumab combination with a OS of 22&#46;0 months&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> This strategy has now been included in the National Comprehensive Cancer Network guidelines incorporating immunotherapy to the treatment of SCLC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although ICIs have already changed the scenario of advanced NSCLC and SCLC&#44; with better outcomes and less toxicity compared to traditional chemotherapy&#44; one of the major challenges that remains is the selection of patients who will benefit from this approach&#46; Another open question is which drug or combination might provide the strongest benefit for each patient&#46; Therefore&#44; although these drugs will be available for most patients&#44; it will be important to identify robust predictive biomarkers of benefit in order to save unnecessary toxicities and financial cost&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Translational research in this field is of upmost importance and has provided hints of potentially relevant biomarkers in addition to PD-L1 expression and TMB&#44; such as tumour lymphocytic infiltrate phenotype&#44; gene signatures&#44; mutation clonality or TCR &#40;T-cell receptor&#41; specificities&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The future seems bright for patients with lung cancer who will receive immunotherapy and new approaches with new immunotherapy strategies &#40;vaccines&#44; 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Editorial
Immunotherapy is Here to Stay: A New Treatment Paradigm in Lung Cancer
La inmunoterapia llega para quedarse: Un nuevo paradigma de tratatamiento en cáncer de pulmón
Pedro Rochaa, Edurne Arriolaa,b,
Corresponding author
earriola@parcdesalutmar.cat

Corresponding author.
a Servei d’Oncologia Médica, Hospital del Mar, Barcelona, Spain
b IMIM (Institut Hospital del Mar d’Investigacions Mèdiques), Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The treatment paradigm of lung cancer has dramatically changed in recent years with the introduction of immunotherapy&#46; Immune checkpoints inhibitors &#40;ICIs&#41; are antibodies that target the brakes to the effective immune response mediated by CTLA-4 &#40;cytotoxic T-lymphocyte-associated 4&#41; and PD-1 &#40;programmed death 1&#41;&#47;PD-L1 &#40;programmed death ligand-1&#41;&#44; releasing these inhibition points&#46; This mechanism of action enhances T-cell mediated immunity&#44; increasing T cell activation and trafficking to the tumour as well as potentiating the effector functions of the host&#39;s immune system&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">ICIs&#44; particularly the anti-PD-1&#47;PD-L1 have changed the standard treatment for the majority of patients with Non-Small Cell Lung Cancer &#40;NSCLC&#41;&#46; In the metastatic setting&#44; patients currently need to be sub-classified upfront into molecularly distinct groups through genomic testing &#40;<span class="elsevierStyleItalic">EGFR&#44; ALK&#44; ROS1</span>&#41; and need to be analyzed for PD-L1 status by immunohistochemistry&#46; In patients with tumour PD-L1 expression &#8805;50&#37; &#40;approximately 33&#37; of all patients&#41; in the first line setting&#44; the anti-PD-1 agent pembrolizumab is superior to chemotherapy with a platinum doublet&#46; In the phase 3 trial &#40;KEYNOTE 024&#41; pembrolizumab demonstrated an improvement of more than four months for median progression free survival &#40;mPFS&#41; and a 40&#37; risk reduction of death compared to chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recently combination strategies &#40;with chemotherapy or two ICIs&#41; have shown very interesting results&#46; The KEYNOTE 189 has demonstrated superiority of platinum-pemetrexed plus pembrolizumab in non-squamous NSCLC in all comers &#40;regardless of PD-L1&#41; with a gain of approximately 4 months in mPFS and potentially increased survival &#40;immature data&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> In the metastatic squamous NSCLC setting &#40;regardless of PD-L1 expression&#41;&#44; the KEYNOTE 407 trial&#44; which compares carboplatin-paclitaxel or nab-paclitaxel with or without pembrolizumab&#44; demonstrated an increase in ORR &#40;58&#46;4&#37; vs 35&#46;0&#37;&#41; and OS of 4&#46;6 months&#44; both results favouring the pembrolizumab containing arm&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Moreover&#44; the combination of anti-CTLA-4 &#40;ipilimumab&#41; and anti-PD-1&#40;nivolumab&#41; has been tested against chemotherapy in the CheckMate 227&#46; In this study&#44; patients were stratified according to tumour mutational burden &#40;TMB&#41; that accounts for the number of non-synonymous mutations per megabase in the tumour &#40;mutations&#47;megabase&#41;&#46; The combination of ipilimumab plus nivolumab in patients with a TMB &#8805;10 &#40;44&#46;2&#37; of all patients evaluated&#41;&#44; achieved a two month increase in mPFS&#44; with a 1-year PFS rate of 42&#46;6&#37; vs 13&#46;2&#37; in the chemotherapy arm&#44; despite the toxicity from the combination which leads to discontinuation of 17&#46;4&#37; compared to 8&#46;9&#37; of patients who received chemotherapy&#46; Importantly&#44; the percentage of patients with response who had an ongoing response after 1 year was 68&#37; with nivolumab plus ipilimumab and 25&#37; with chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> The toxicity profile&#44; the availability of tissue and techniques in not all centres to perform TMB could be one of the limitations to the use of this combination&#46; These trials will change the standard treatment in the following months incorporating combination strategies in the first-line setting&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In second-line treatment&#44; after chemotherapy failure&#44; two ICIs &#40;nivolumab&#44; and atezolizumab&#41; have demonstrated superior outcomes in patients when compared to standard chemotherapy with docetaxel regardless of histology or PD-L1 status&#46; Pembrolizumab has shown improved efficacy with the same comparator in patients with PD-L1 &#8805;1&#37;&#46; These are currently approved treatments based on the results of CheckMate 017 and CheckMate 057 for nivolumab&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#44;7</span></a> KEYNOTE 010 for pembrolizumab<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> and OAK trial for atezolizumab&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> All trials showed a clear benefit in Objective Response Rate &#40;ORR&#41; and Overall Survival &#40;OS&#41; with less toxicity compared to docetaxel&#46; Overall&#44; the results were similar between all trials with an ORR around 20&#37; and median OS between 10 and 13 months&#46; Interestingly&#44; in all trials patients with higher PD-L1 expression showed an increased probability of response&#44; although PD-L1 is not a perfect predictive nor prognostic marker in lung cancer&#46; One of the unique and most important results with immunotherapy is the consistent long-term survival queue observed in all trials&#46; The study with the longest follow-up with immunotherapy in lung cancer has reported 16&#37; of patients being alive after 5 years of follow up after stopping treatment &#40;maximum immunotherapy duration of 2 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In locally advanced unresectable patients&#44; where chemoradiotherapy is standard treatment&#44; immunotherapy with the anti-PD-L1 agent durvalumab has also shown benefit&#46; In the PACIFIC trial&#44; patients with stage III NSCLC who did not present a disease progression after platinum-based chemoradiotherapy were randomized to receive durvalumab or placebo during 1 year&#46; A significant benefit in mPFS&#44; of more than 11 months was demonstrated in the durvalumab arm&#44; and with a median time to death or metastasis of 23&#46;2 months with durvalumab Vs 14&#46;6 months with placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> These results have incorporated immunotherapy with ICIs in the locally advanced and metastatic setting of virtually all patients with lung cancer&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Immunotherapy is now being evaluated in earlier stages&#46; A recent report has evaluated the role of neoadjuvant immunotherapy in early stages &#40;I&#44; II and IIIA&#41; for resectable NSCLC&#46; In this small study patients received two cycles of nivolumab before surgery&#46; Results revealed 45&#37; of cases with major pathological response&#44; with a few adverse events and without delay in planned surgery&#46; If confirmed in larger studies&#44; immunotherapy might represent a new tool in the neoadjuvant setting as well&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">ICIs have also been tested in Small-Cell Lung Cancer &#40;SCLC&#41; where systemic treatment has not changed for 30 years&#46; Initial studies tested ipilimumab in combination with chemotherapy in advanced disease and despite the negative results compared with chemotherapy alone&#44; a subgroup of patients presented durable responses and unexpectedly long survival&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the chemoresistant setting&#44; the CheckMate 032&#44; a phase 2 trial&#44; compared nivolumab Vs nivolumab plus ipilimumab in this setting&#46; Encouraging results with nivolumab but particularly from the combination were obtained in this refractory setting with 10&#8211;23&#37; of objective responses&#44; respectively&#46; In a retrospective exploratory analysis&#44; PD-L1 was not a predictive marker for benefit but TMB appeared to select patients who benefited most&#44; particularly from the ipilimumab and nivolumab combination with a OS of 22&#46;0 months&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> This strategy has now been included in the National Comprehensive Cancer Network guidelines incorporating immunotherapy to the treatment of SCLC&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Although ICIs have already changed the scenario of advanced NSCLC and SCLC&#44; with better outcomes and less toxicity compared to traditional chemotherapy&#44; one of the major challenges that remains is the selection of patients who will benefit from this approach&#46; Another open question is which drug or combination might provide the strongest benefit for each patient&#46; Therefore&#44; although these drugs will be available for most patients&#44; it will be important to identify robust predictive biomarkers of benefit in order to save unnecessary toxicities and financial cost&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Translational research in this field is of upmost importance and has provided hints of potentially relevant biomarkers in addition to PD-L1 expression and TMB&#44; such as tumour lymphocytic infiltrate phenotype&#44; gene signatures&#44; mutation clonality or TCR &#40;T-cell receptor&#41; specificities&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The future seems bright for patients with lung cancer who will receive immunotherapy and new approaches with new immunotherapy strategies &#40;vaccines&#44; TILs&#44; CAR-T cells&#44; other checkpoint agonists and antagonists&#41; will certainly achieve promising outcomes for our patients&#46;</p></span>"
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ISSN: 03002896
Original language: English
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