Abnormalities in the KRAS Gene and Treatment Options for NSCLC Patients with the G12C Mutation in This Gene-A Literature Review and Single-Center Experience.

Mutations in the KRAS gene are among the most common mutations observed in cancer cells, but they have only recently become an achievable goal for targeted therapies. Two KRAS inhibitors, sotorasib and adagrasib, have recently been approved for the treatment of patients with advanced non-small cell lung cancer with the KRAS G12C mutation, while studies on their efficacy are still ongoing. In this work, we comprehensively analyzed RAS gene mutations' molecular background, mutation testing, KRAS inhibitors' effectiveness with an emphasis on non-small cell lung cancer, the impact of KRAS mutations on immunotherapy outcomes, and drug resistance problems. We also summarized ongoing trials and analyzed emerging perspectives on targeting KRAS in cancer patients.

Breaking the 'Undruggable' Barrier: Anti-PD-1/PD-L1 Immunotherapy for Non-Small Cell Lung Cancer Patients with KRAS Mutations-A Comprehensive Review and Description of Single Site Experience.

Kirsten rat sarcoma viral oncogene homologue (KRAS) gene mutations are among the most commonly found oncogenic alterations in non-small cell lung cancer (NSCLC) patients. Unfortunately, KRAS mutations have been considered "undruggable" for many years, making treatment options very limited. Immunotherapy targeting programmed death-ligand 1 (PD-L1), programmed death 1 (PD-1) and cytotoxic T lymphocyte antigen 4 (CTLA-4) has emerged as a promising therapeutic option for NSCLC patients. However, some studies have suggested a lower response rate to immunotherapy in KRAS-mutated NSCLC patients with the coexistence of mutations in the STK11 (Serine/Threonine Kinase 11) gene. However, recent clinical trials have shown promising results with the combination of immunotherapy and chemotherapy or immunotherapy and KRAS inhibitors (sotorasib, adagrasib) in such patients. In other studies, the high efficacy of immunotherapy has been demonstrated in NSCLC patients with mutations in the KRAS gene that do not coexist with other mutations or coexist with the TP53 gene mutations. In this paper, we review the available literature on the efficacy of immunotherapy in KRAS-mutated NSCLC patients. In addition, we presented single-site experience on the efficacy of immunotherapy in NSCLC patients with KRAS mutations. The effectiveness of chemoimmunotherapy or immunotherapy as well as KRAS inhibitors extends the overall survival of advanced NSCLC patients with the G12C mutation in the KRAS gene to 2-3 years. This type of management has become the new standard in the treatment of NSCLC patients. Further studies are needed to clarify the potential benefits of immunotherapy in KRAS-mutated NSCLC patients and to identify potential biomarkers that may help predict response to therapy.

Effectiveness of ALK inhibitors in treatment of CNS metastases in NSCLC patients.

Metastases to the central nervous system (CNS) in patients with non-small cell lung cancer constitute an extremely difficult clinical problem, and their occurrence is associated with a poor prognosis. Due to the existence of the blood-brain barrier (BBB) and the action of proteins responsible for the transport of drugs, e.g. P-glycoprotein (P-gp), the penetration of drugs into the CNS is insufficient. Until recently, the only method of CNS metastases treatment was radiotherapy and neurosurgery. The advancement of molecular biology allowed discover targets for molecularly targeted therapies. One of targets is abnormal anaplastic lymphoma kinase, which results from the rearrangement of the ALK gene in patients with non-small cell lung cancer (NSCLC). ALK rearrangement occurs in only about 4.5% of NSCLC patients, but its presence favors brain metastases. The ALK inhibitors (ALKi) were modified to obtain molecules with high ability to penetrate into the CNS. This was achieved by modifying the structure of individual molecules, which became, inter alia, less substrates for P-gp. These modifications caused that less than 10% of patients experience progression in CNS during new ALK inhibitors treatment. This review summarizes the knowledge about the action of BBB, the pharmacodynamics and pharmacokinetics of ALKi, with particular emphasis on their ability to penetrate the CNS and the intracranial activity of individual drugs from different generations of ALK inhibitors.

ALK gene rearrangement favors the development of central nervous system (CNS) metastases in patients with NSCLC. New generations of ALK inhibitors penetrate the CNS and induce an intracranial response and protect against new brain lesions.

Crizotinib efficacy in advanced non-squamous NSCLC patients with ALK or ROS1 rearrangement.

In patients with advanced non-small cell lung cancer (NSCLC), comprehensive genetic diagnostics is currently carried out in order to qualify for molecularly targeted therapies and immunotherapy. The aim of the study was to assess the usefulness of the reverse transcriptase (RT-PCR) method in the diagnosis of gene rearrangements, the effectiveness of EGFR, ALK, ROS1, and PD-L1 inhibitors in first-line treatment in NSCLC patients. We enrolled 95 non-squamous NSCLC patients with known status of EGFR, ALK, ROS1, MET and RET genes and PD-L1 protein expression. We used the real time PCR, fluorescence in situ hybridization (FISH), immunohistochemistry (IHC) and RT-PCR techniques for determination of predictive factors. In patients with ALK and ROS1 genes alteration, the median overall survival was 34 months in crizotinib treated patients and 6 months in patients who received chemotherapy (HR = 0.266, p = 0.0056). The risk of death was lower in patients treated with molecularly targeted therapies or immunotherapy compared to patients with predictive factors without personalized treatment (HR = 0.265, 95% CI 0.116-0.606) and to patient without predictive factors who received chemotherapy (HR = 0.42, 95% CI 0.162-1.09). Diagnosis of predictive factors and implementation of personalized treatment are key to prolonging the survival in advanced NSCLC patients.

Immunoprofiling: An Encouraging Method for Predictive Factors Examination in Lung Cancer Patients Treated with Immunotherapy.

The efficiency of immunotherapy using monoclonal antibodies that inhibit immune checkpoints has been proven in many clinical studies and well documented by numerous registration approaches. To date, PD-L1 expression on tumor and immune cells, tumor mutation burden (TMB), and microsatellite instability (MSI) are the only validated predictive factors used for the qualification of cancer patients for immunotherapy. However, they are not the ideal predictive factors. No response to immunotherapy could be observed in patients with high PD-L1 expression, TMB, or MSI. On the other hand, the effectiveness of this treatment method also may occur in patients without PD-L1 expression or with low TMB and with microsatellite stability. When considering the best predictive factor, we should remember that the effectiveness of immunotherapy relies on an overly complex process depending on many factors. To specifically stimulate lymphocytes, not only should their activity in the tumor microenvironment be unlocked, but above all, they should recognize tumor antigens. The proper functioning of the anticancer immune system requires the proper interaction of many elements of the specific and non-specific responses. For these reasons, a multi-parameter analysis of the immune system at its different activity levels is considered a very future-oriented predictive marker. Such complex immunological analysis is performed using modern molecular biology techniques. Based on the gene expression studies, we can determine the content of individual immune cells within the tumor, its stroma, and beyond. This includes all cell types from active memory cytotoxic T cells, M1 macrophages, to exhausted T cells, regulatory T cells, and M2 macrophages. In this article, we summarize the possibilities of using an immune system analysis to predict immunotherapy efficacy in cancer patients. Moreover, we present the advantages and disadvantages of immunoprofiling as well as a proposed future direction for this new method of immune system analysis in cancer patients who receive immunotherapy.

Two Complementarity Immunotherapeutics in Non-Small-Cell Lung Cancer Patients-Mechanism of Action and Future Concepts.

Due to the limited effectiveness of immunotherapy used as first-line monotherapy in patients with non-small-cell lung cancer (NSCLC), the concepts of combining classical immunotherapy based on immune checkpoint antibodies with other treatment methods have been developed. Pembrolizumab and atezolizumab were registered in combination with chemotherapy for the treatment of metastatic NSCLC, while durvalumab found its application in consolidation therapy after successful chemoradiotherapy in patients with locally advanced NSCLC. Exceptionally attractive, due to their relatively low toxicity and high effectiveness, are treatment approaches in which a combination of two different immunotherapy methods is applied. This method is based on observations from clinical trials in which nivolumab and ipilimumab were used as first-line therapy for advanced NSCLC. It turned out that the dual blockade of immune checkpoints activated T lymphocytes in different compartments of the immune response, at the same time affecting the downregulation of immune suppressor cells (regulatory T cells). These experiments not only resulted in the registration of combination therapy with nivolumab and ipilimumab, but also initiated other clinical trials using immune checkpoint inhibitors (ICIs) in combination with other ICIs or activators of costimulatory molecules found on immune cells. There are also studies in which ICIs are associated with molecules that modify the tumour environment. This paper describes the mechanism of the synergistic effect of a combination of different immunotherapy methods in NSCLC patients.

Impact of copy number variant and single nucleotide polymorphism of the programmed death-ligand 1 gene, programmed death-ligand 1 protein expression and therapy regimens on overall survival in a large group of Caucasian patients with non-small cell lung carcinoma.

Anti-programmed death-1 or anti-programmed death-ligand 1 (PD-L1) blockade may be ineffective in some patients with non-small cell lung cancer (NSCLC) with high percentage of tumor cells with PD-L1 expression. In addition, immunotherapy may provide great benefits in patients without PD-L1 expression. The present study assessed PD-L1 protein expression by immunohistochemistry, copy number variation (CNV) of PD-L1 and two single nucleotide polymorphisms (SNPs), rs822335 and rs822336, in the promoter of PD-L1 by quantitative PCR in 673 patients with NSCLC. Overall survival time of patients with NSCLC depending on the assessed predictive factors (PD-L1 CNV or SNP) and the treatment methods (immunotherapy in first/second line of treatment or chemotherapy) was analyzed. The present study revealed significantly higher PD-L1 copies number in patients with ≥10% and ≥50% of tumor cells with PD-L1 expression compared to patients with lower percentage of PD-L1-positive tumor cells (P=0.02 and P=0.0002, respectively). There was a significant positive correlation (R=0.2; P=0.01) between number of PD-L1 copies and percentage of tumor cells with PD-L1 protein expression. Percentage of tumor cells with PD-L1 expression was lower in patients with TT genotype of the rs822335 polymorphism compared to those with CC genotype (P=0.03). The present study observed significantly higher risk of death in patients treated with chemotherapy compared to those treated with immunotherapy (P<0.0001; hazard ratio=2.4768; 95% confidence interval, 2.0120-3.0490). The present study demonstrated a close relationship between PD-L1 copies number, genotype of rs822335 PD-L1 polymorphism and PD-L1 protein expression on tumor cells. However, the impact of CNV and SNPs of PD-L1 on overall survival of patients with NSCLC requires further investigation.

Supersonic jet spectroscopy of parent hemiporphycene: Structural assignment and vibrational analysis for S0 and S1 electronic states.

Hemiporphycene (HPc), a constitutional isomer of porphyrin, is studied under supersonic expansion conditions by means of laser-induced fluorescence, visible-visible hole-burning experiments, single vibronic level fluorescence techniques, and quantum chemical calculations. Only one trans form of jet-cooled HPc is observed, in contrast to solution studies that evidence a mixture of two trans tautomeric forms separated in energy by ∼1 kcal/mol. Reliable structural assignment is provided by simulating absorption and emission patterns at the density functional theory and time-dependent density functional theory levels of theory. The vibronic spectra are nicely reproduced for both electronic ground and lowest excited singlet states for the most stable trans form. In contrast to another porphyrin isomer, porphycene (Pc), no tunneling or photo-induced hydrogen transfer is detected. The lower symmetry of HPc compared with Pc and the concomitant non-equivalent positions of the inner-cavity nitrogen atoms result in a non-symmetric double minimum potential for tautomerization, larger energy barrier, and a longer tunneling distance, with the average intramolecular hydrogen bond length larger in HPc than in Pc. HPc readily forms hydrates that show red-shifted absorption relative to the bare molecule.

Non-typical fluorescence studies of excited and ground state proton and hydrogen transfer.

Fluorescence studies of tautomerization have been carried out for various systems that exhibit single and double proton or hydrogen translocation in various environments, such as liquid and solid condensed phases, ultracold supersonic jets, and finally, polymer matrices with single emitters. We focus on less explored areas of application of fluorescence for tautomerization studies, using porphycene, a porphyrin isomer, as an example. Fluorescence anisotropy techniques allow investigations of self-exchange reactions, where the reactant and product are formally identical. Excitation with polarized light makes it possible to monitor tautomerization in single molecules and to detect their three-dimensional orientation. Analysis of fluorescence from single vibronic levels of jet-isolated porphycene not only demonstrates coherent tunneling of two internal protons, but also indicates that the process is vibrational mode-specific. Next, we present bifunctional proton donor-acceptor systems, molecules that are able, depending on the environment, to undergo excited state single intramolecular or double intermolecular proton transfer. For molecules that have donor and acceptor groups located in separate moieties linked by a single bond, excited state tautomerization can be coupled to mutual twisting of the two subunits.

Supersonic Jet Spectroscopy and Density Functional Theory Study of Isomeric Diazines: 1,4- and 1,8-Diazatriphenylene. Why Do They Differ So Deeply?

We report on laser-induced fluorescence excitation and dispersed fluorescence spectra of two isomeric compounds: 1,4- and 1,8-diazatriphenylene (1,4- and 1,8-DAT) isolated in supersonic molecular jets, and their 1:1 complexes with protic solvents. We found that the ground and excited state vibronic patterns of bare 1,4-DAT differ significantly from those of 1,8-DAT, and those of the complexes of both isomers. A marked activity of several out-of-plane vibrations in 1,4-DAT and the symptoms of the distortion of the S1 excited molecule were diagnosed from the vibronic spectra, whereas planar structures were predicted for 1,8-DAT in S0 and S1 states. An anharmonic double-minimum potential along an out-of-plane coordinate has been derived and used to predict higher overtones of the S1 state vibration at 113 cm-1. Large enhancement of fluorescence was observed upon formation of 1:1 complexes of 1,4-DAT with water or methanol, which is explained in terms of an increased separation of interacting (n,π*) and (π,π*) electronic states in the H-bonded complexes, and/or a suppression of the intersystem crossing process.

Ultrafast photodynamics of drugs in nanocavities: cyclodextrins and human serum albumin protein.

In this feature article, we discuss recent advances in studying ultrafast dynamic and structural aspects of host-guest interactions. Steady-state and time-resolved techniques exploring events from the femto- to nanosecond regime were used to examine the ultrafast photodynamics and subsequent events in selected nanostructures of the formed complexes. These consist of aromatic systems, biologically relevant molecules, and drugs trapped within cyclodextrins (CD) and human serum albumin (HSA) protein pockets. We examine the effects exerted by these chemical and biological cavitands on internal twisting motions, proton transfer and charge transfer, and cis-trans isomerization reactions that may occur in the confined molecular systems. In addition, the influence of a restricting environment on the interaction of guest molecules with biological water is considered. The dynamic details of the complexes (diffusion, early interactions, formation, stability, internal guest diffusion, and conformational changes) and the excited-state relaxation pathways, rate constants of the involved processes, and changes in the electronic distribution within encapsulated guests gave clues to elucidate their photobehavior and are relevant to the photostability and delivery of drugs when using nanocarriers.

Photo-deactivation pathways of a double H-bonded photochromic Schiff base investigated by combined theoretical calculations and experimental time-resolved studies.

The photophysics of N,N'-bis(salicylidene)-p-phenylenediamine (BSP) is analyzed both theoretically and experimentally. The alternative intramolecular proton-transfer reactions lead to three different tautomers. We performed DFT and TDDFT calculations to analyze the topography of the reactions connecting the three tautomers. Deactivation paths through a Conical Intersection (CI) region are also analyzed to explain the low fluorescence quantum yield of the phototautomers. The complex molecular structure of BSP provides a large number of deactivation paths, almost all of them energetically available following the initial photoexcitation. Femtosecond (fs) time-resolved emission studies in solution and flash photolysis experiments (nano to millisecond regime) were performed to get detailed information on the time domain of the full photocycle. The picture that emerges by combining theoretical and experimental results shows a very fast (less than 100 fs) photoinduced single proton transfer process leading to a phototautomer where a single proton has moved. This species may deactivate through a low-energy CI leading in about 20 ps to a rotameric form in the ground state that has a lifetime of several tens of microseconds in solution. This process competes with another deactivation path taking place prior to the proton-transfer reaction which involves a low-energy CI leading to a rotamer of the enol structure. In the flash photolysis studies, the rotamer of the enol structure was directly identified by the positive transient absorption band in the 250-260 nm and its lifetime in n-hexane (10 ms) is almost 3 orders of magnitude longer than the lifetime of the photochrome (around 40 µs). Our findings do not exclude a double proton transfer reaction in the excited enol form to give a tautomer in less than 100 fs during the first (impulsive) phase of the reaction which reverts back to the photoproducts of the simple proton transfer in 1-3 ps.

Stability and photodynamics of lumichrome structures in water at different pHs and in chemical and biological caging media.

We report on photophysical studies of lumichrome (Lc) in water at different pHs, and interacting with the human serum albumin (HSA) protein and ß-cyclodextrin (ß-CD) in neutral aqueous solutions. We used steady-state and picosecond time-resolved emission spectroscopy to investigate the structural changes of Lc at the ground and excited states, as well as the rotational dynamics of the complexes with HSA and ß-CD. In neutral water, the predominant neutral alloxazine-type structure of Lc coexists with a small population of the anionic form. In the presence of HSA, we observed an increase in the absorption band intensity at 450 nm. This increase is due to a preferential complexation (1:1 stoichiometry, K=8600 M(-1)) of the Lc anion structures within the protein. This change is not observed when ß-CD is added, in which the Lc neutral form is exclusively complexed, giving a 1:1 stoichiometry. The fluorescence lifetimes of Lc in neutral water solutions are 4.2 and 2.3 ns, assigned to anionic and neutral alloxazinic forms, respectively. Using ß-CD, the lifetime of the 1:1 complexes is 0.74 ns, while in the case of HSA complexes we observed two lifetimes (0.83 and 0.14 ns), which we explained in terms of different interactions of the anions with the protein. The rotational relaxation time of free Lc in neutral water is 75 ps. For Lc:ß-CD complexes this time is 0.44 ns, in full agreement with the expected value from the hydrodynamic theory. For HSA solutions, we obtained a distribution of values between ∼1 and 4.5 ns, suggesting a site heterogeneity of complexation and a different strength of binding for the involved Lc anionic forms. Our results give information about the different photorelaxation behavior of Lc within chemical and biological cavities, and might help in a better design of nanosystems for drug carriers and delivery.

Unusual, solvent viscosity-controlled tautomerism and photophysics: meso-alkylated porphycenes.

Stationary and time-resolved studies of 9,10,19,20-tetramethylporphycene and 9,10,19,20-tetra-n-propylporphycene in condensed phases reveal the coexistence of trans and cis tautomeric forms. Two cis configurations, cis-1 and cis-2, play a crucial role in understanding the excited-state deactivation and tautomer conversion dynamics. The trans-trans tautomerization, involving intramolecular transfer of two hydrogen atoms, is extremely rapid (k ≥ 10(13) s(-1)), both in the ground and lowest electronically excited states. The cis-1-trans conversion rate, even though the process is thermodynamically more favorable, is much slower and solvent-dependent. This is explained by the coupling of alkyl group rotation with the hydrogen motion. Excited-state deactivation is controlled by solvent viscosity: the S(1) depopulation rate decreases by more than 2 orders of magnitude when the chromophore is transferred from a low-viscosity solution to a polymer film. Such behavior confirms a model for excited state deactivation in porphycene, which postulates that a conical intersection exists along the single hydrogen transfer path leading from the trans to a high energy cis-2 tautomeric form. For this process, the tautomerization coordinate includes not only hydrogen translocation but also large-amplitude twisting of the two protonated pyrrole moieties attached to the opposite sides of the ethylene bridge.

What is the difference between the dynamics of anion- and keto-type of photochromic salicylaldehyde azine?

The normal and anion structures of salicylaldehyde azine (SAA) in solvents of different viscosities and polarities have been studied by means of femto- to nanosecond time-resolved emission techniques. In the normal form, an excited-state intramolecular proton-transfer (ESIPT) reaction takes place with a time constant shorter than 80 fs to produce an excited keto-type tautomer in which intramolecular-vibrational energy redistribution and vibrational cooling occur in 100 fs to 2 ps. The viscosity-dependent emission decay in the red part of the spectrum with 5-11 ps reflects a twisting motion leading to rotamers of these keto-type structures, most probably of (n,pi*) nature. For the anion type, the viscosity dependent rise-times (3 to 400 ps) at the red part of the emission, and the wavelength-dependent fluorescence lifetimes (20 to 1100 ps) indicate a stepwise formation of different conformers of the anions. The results reported here should be relevant to a better understanding of the photobehaviour of photochromic compounds and charged chromophores in biological systems.

On the origin of radiationless transitions in porphycenes.

A model for the radiationless deactivation of porphycenes has been proposed based on the theoretical prediction that the lowest electronic state of one of the cis tautomeric forms corresponds to an open-shell nonplanar structure. The radiationless channel is provided by crossing of the potential energy surfaces of the ground and lowest excited states along the hydrogen-transfer coordinate. The model explains the large dependence of fluorescence of several porphycenes on viscosity. It also allows prediction of the emissive properties for differently substituted porphycenes.

Femtosecond dynamics of piroxicam structures in solutions.

We report on studies of femtosecond dynamics of a nonsteroidal anti-inflammatory drug, piroxicam (1), in water at three different pHs and for comparison in two aprotic solvents. An ultrafast excited-state proton-transfer (ESIPT) process takes place in neutral and cationic enol-type structures. Femtosecond emission and transient absorption experiments show that this reaction is barrierless, and the proton-transferred keto tautomer is formed in less than 100 fs in both organic solvents and acidic water. In neutral and alkaline water, the ESIPT is not present because of the prevalence of the anion structures at the ground state. For the excited anions (pH = 7, 11) and formed keto cations (pH approximately 3), an intramolecular charge-transfer process takes place in times shorter than 0.3 ps. The formed structures have a fluorescence lifetime of approximately 2-5 ps, depending on pH. In contrast, the internal twisting motion in organic solvents is slower (approximately 0.5-1 ps) and gives rotamers with lifetimes of tens of picoseconds. These results clearly show strong interactions of 1 with water, significantly distinct from those present in organic aprotic solvents. We believe that the results are important for a better understanding on short time interactions of drugs with their environment.

Relaxation dynamics of piroxicam structures within human serum albumin protein.

We report on steady-state and ps-time-resolved emission studies of piroxicam (1) drug within human serum albumin (HSA) protein in cyclodextrin and in neat solvents. The steady-state results indicate that 1 binds to HSA protein and that two binding sites are involved. The fluorescence decays corresponding to site I in subdomain IIA and to site II in subdomain IIIA have time constants of approximately 60 ps and approximately 360 ps, respectively. The results suggest that the anion forms bind to site I, whereas the zwitterionic ones bind to site II. The energy-transfer process from excited tryptophan to 1 can occur with moderate efficiency (50%). The rotational time of 1 encapsulated by HSA indicates diffusion within the protein. These findings can be used for a better understanding of piroxicam and HSA interactions.

Observation of three behaviors in confined liquid water within a nanopool hosting proton-transfer reactions.

In this contribution, we report on studies of rotational and diffusional dynamics of 7-hydroxyquinoline (7HQ) within a reverse micelle (RM) containing different amounts of water. Analyzed in terms of the wobbling-in-a-cone model, the data reveal structural and dynamical properties of the nanopool. We clearly observed three regions in the behavior of confined water molecules within the RM hosting a double proton-transfer reaction between the probe and water. This observation remarkably reproduces the change of calculated water density within this life-mimicking medium. The number of water molecules per AOT head in the transition regions changes from 2 to 5, the latter being very near to the full solvation number (6) of the RM heads. Moreover, the H-bonds breaking and making within the RM to give new structures of the probe strongly affect the environment fluidization in different extents, reflected in different relaxation times of these structures; however, they are of similar sizes. We discuss the role of RM confinement and the proton-transfer dynamics on the behavior of water and their relationships to the packing of water molecules in the studied range of concentrations.

Vibrational gating of double hydrogen tunneling in porphycene.

A procedure that enables determining the reaction rate from the analysis of fluorescence anisotropy is described and applied to the investigation of double hydrogen transfer between inner-cavity nitrogen atoms in electronically excited porphycene. Tautomerization proceeds as a thermally activated synchronous double hydrogen tunneling. The barrier to the reaction is dynamically modulated by a vibration that simultaneously changes the strength of two intramolecular hydrogen bonds. Different mechanisms of tautomerization in porphycene and its parent isomer, porphyrin, can be understood by analyzing the potentials for hydrogen transfer.