Circulating tumor DNA minimal residual disease in clinical practice of non-small cell lung cancer

Figures & data

Figure 1. Timeline of the landmark of MRD analysis in NSCLC. The figure exhibits a timeline of selected significant milestones in MRD that can be applied for analysis of NSCLC.

Table 1. ctDNA MRD evaluation of resectable NSCLC.

Study	Patient type	Stage	Sample size	Assay method	Pre-op ctDNA detection rate	Post-op ctDNA detection rate	ctDNA preceded radiograpc progression	NPV	PPV	ctDNA MRD positive associated with prognosis	Effect of adjuvant therapy on ctDNA MRD positive patients
Abbosh [44] (NCT03004755)	NSCLC	I~III	100	Signatera	48%(46/96) (46/96)	NA	Median of70 days 70 days	90%(9/10) (9/10)	93%(13/14) (13/14)	NA	The ctDNA profiling reflected adjuvant chemotherapy resistance.[
Chen et al. [67] NCT02965391	NSCLC	I-IIIA	205	cSMART	NA	19.2% (34/177)	Median of165 days 165 days	93%(14/15) (14/15)	NA	NA	RFS of ctDNA positive patients receiving adjuvant therapy (269 days) was better than that of non adjuvant therapy (111 days).
Peng et al. [65]	NSCLC	I~IV	77	cSMART	59.7%(46/77) (46/77)	42.25% (30/71)	Median of12.6 months 12.6 months	NA	63.3% (19/30)	Lower RFS and OS	NA
Qiu et al. [68]	NSCLC	I~III	103	ATG-Seq	69.3%(61/88) (61/88)	21.2%(18/85) (18/85)	Median of88 days 88 days	60%(3/5) (3/5)	79.4%(27/34) (27/34)	Lower RFS	NA
Zviran et al. [69]	LUAD	Ia~IV	39	MRDetect	NA	45.45% (10/22)	NA	100%(12/12) (12/12)	50%(5/10) (5/10)	Lower RFS	NA
Ohara et al. [70]	Lung cancer	IIa – IIIa	20	CAPP-seq	40%(8/20) (8/20)	20%(4/20) (4/20)	NA	NA	75%(3/4) (3/4)	Lower RFS	NA
Kuang et al. [66] (NCT03465241)	NSCLC	Ib~IIIb	38	Targeted NGS	50%(19/38) (19/38)	22.9%(8/35) (8/35)	NA	81.5%(22/27) (22/27)	50%(4/8) (4/8)	Lower RFS	The prognosis of patients with continuous positive ctDNA or from negative to positive after chemotherapy was poor.
Xia et al. [83] (NCT03317080)	NSCLC	I – III	330	MinerVa MRD assay	2.9% (69/330)	7.9% (26/329)	NA	83.8%(254/303) (254/303)	8.8%(21/26) (21/26)	Worse RFS	The recurrence rate of patients with positive ctDNA MRD after adjuvant therapy is low.
Waldeck et al. [92] (DRKS0000952)	NSCLC	Ia-IIIb	33	Targeted NGS	57%(12/21) (12/21)	19% (4/21)	NA	66%(8/12) (8/12)	100%(4/4) (4/4)	Lower RFS and OS	NA
Zhang et al. [71]	NSCLC	I-III	261	Targeted NGS	36.4% (95/261)	27.8% (174/652)	median of3.4 month 3.4 month	96.8%(184/190) (184/190)	89.1%(41/46) (41/46)	NA	Patients with detectable MRD benefit from adjuvant therapy.
Tang et al. [74] (NCT01725165)	NSCLC	IV	31	Targeted NGS	NA	NA	median of6.7 months 6.7 months	NA	83.3%(5/6) (5/6)	NA	NA

Note: LUAD, adenocarcinoma of lung. NSCLC, non- small cell lung cancer. NGS, next-generation sequencing. NPV, negative predictive value. PPV, positive predictive value. PFS, progression-free survival. OS, overall survival. Post-op, postoperative. Pre-op, preoperative. MRD, minimal residual disease. NA, not assessed.

Table 2. Main detection techniques of ctDNA.

Platform	Assay method	Type of alteration	Advantage(s)	Limitation(s)	Reported LOD (% of cfDNA)
Conventional PCR	Amplification refractory mutation system PCR [53]	Known hotspot alterations	Ease of use, lowest cost	Detects only known mutations or a small number of variants concurrently; low sensitivity	~0.1–1
Digital PCR	Droplet digital PCR [54] BEAMing (beads, emulsion, amplification, and magnetics) [55]	Known point mutations, genomic rearrangements	High sensitivity, absolute quantification, rare allele detection	Detects only known mutations or a small number of variants	~0.01
Targeted deepsequencingsequencing	TAm-Seq [56] Safe-SeqS [56,57] CAPP-Seq [36] iDES-enhanced CAPP-seq [58] PhasED-seq [59] MSK-IMPACT [60]	Known point mutations, selected SNVs, CNVs, and rearrangements across targeted regions	High sensitivity, relatively inexpensive	Detects only known mutations; less comprehensive than other NGS methods; incapable of detecting SCNAs and fusions without assay personalization	0.00016–2.0

Table 3. ctDNA MRD evaluation of unresectable NSCLC.

Study	Patient type	Stage	Sample size	Assay method	ctDNA positive	ctDNA preceded radiographic progression	NPV	PPV	ctDNA responders associated with prognosis
Chaudhuri et al. [40]	Lung cancer	I – III	40	CAPP-seq	ADC:89%SCC:93%, others:100% SCC:93%, others:100%	Median of5.2 months 5.2 months	93%(14/15) (14/15)	100%(20/20) (20/20)	FFP: 0%
Moding [77]	NSCLC	IIb-IIIb	65	CAPP-Seq	43.18% (19/44)	Mean of 4.1 months	86.7% (13/15)	86% (6/7)	FFP: CTR, ctDNA positive was 0%, ctDNA negative was 100%; CTR + ICI, ctDNA positive was 0%, ctDNA negative was 87.5%
Xia et al. [78] (NCT02442349)	LUAD of EGFR T790M positive	IV	8	Targeted NGS	100% (8/8)	Average of3.0 months 3.0 months	NA	NA	The decrease in methylation level and maxAF reflected treatment efficacy.
Hellmann et al. [79]	NSCLC	IV	31	CAPP-Seq	100%	Median of4.4 months 4.4 months	93%(25/27) (25/27)	100%(4/4) (4/4)	NA
Goldberg et al. [80]	NSCLC	IV	49	Multigene NGS	57%(28/49) (28/49)	Median of48 days 48 days	100%(11/11) (11/11)	76.9%(10/13) (10/13)	Time on treatment was significantly longer for ctDNA responders versus non-responders (205.5 vs. 69 days).
Jia et al. [81]	NSCLC	IIIb/IV	10	WGS+WES	NA	NA	NA	NA	The ctDNA abundance decrease predicted prolonged PFS.

Note: LUAD, adenocarcinoma of lung. NSCLC, non- small cell lung cancer. NGS, next-generation sequencing. WES, whole exome sequencing. NPV, negative predictive value. PPV, positive predictive value. PFS, progression-free survival. OS, overall survival. FFP, freedom from Progression. CTR, chemoradiation therapy. CICI, consolidation immune checkpoint inhibition. NA, not assessed.

Table 4. Ongoing studies utilizing ctDNA MRD monitoring in NSCLC.

Study	Phase	Patient type	Stage	Sample size	Intervention/treatment	Primary Outcome Measures	MRD
MERMAID-1 (NCT04385368)	3	NSCLC	II-III	332	Durvalumab + SoC chemotherapy vs. placebo + SoC chemotherapy	DFS in MRD+ analysis set (RECIST 1.1) [Time frame: approximately 4 years]	The treatment effect was evaluated according to the DFS of MRD positive patients.
MERMAID-2 (NCT04642469)	3	NSCLC	II-III	26	Durvalumab vs. placebo	DFS in PD-L1 TC ≥ 1% (RECIST 1.1) [Time frame: approximately 5 years]	The treatment efficacy and safety were evaluated based on MRD positive patients during the 96 weeks monitoring period.
(NCT04585477)	2	NSCLC	I – III	80	Durvalumab	Decrease in ctDNA Level [Time frame: 8 weeks]	The number without dispersion of participants who have a ≥ 3-fold drop in ctDNA MRD levels after 2 cycles of durvalumab treatment.
SCION (NCT04944173)	2	NSCLC	I	94	Durvalumab	Overall risk of relapse [Time frame: 18 months]	The ctDNA MRD were used to estimated who will benefit from extended treatment with durvalumab.
(NCT05079022)	1/2	LUAD	I	50	Furmonertinib	Clearance of ctDNA at 6 months [Time frame: 6 months]	The ctDNA were used to assess the effectiveness of furmonertinib in stage I LUAD patients and which can be used as an MRD monitoring marker.
(NCT04585490)	3	NSCLC	III	48	Durvalumab+ platinum doublet chemotherapy vs. durvalumab	Change in ctDNA level following chemotherapy [Time frame: 12 weeks]	The change of ctDNA levels in stage III MRD positive unresectable diseases is due to the combination of consolidation chemotherapy and immunotherapy

Note: LUAD, adenocarcinoma of lung. NSCLC, non- small cell lung cancer. DFS, disease free survival. MRD, minimal residual disease. The ongoing clinical research queried from the website https://www.clinicaltrials.gov/.

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