Tumor-infiltrating natural killer cell profiling for therapeutic stratification in patients with resectable non-small cell lung cancer

Objective Neoadjuvant chemoimmunotherapy has improved outcomes in resectable non-small cell lung cancer (NSCLC), yet its real-world implementation is often challenged by surgical delays, immune-mediated fibrosis, and postoperative complications. Smokers with NSCLC, despite a high risk for surgical morbidity, show enhanced responses to neoadjuvant chemoimmunotherapy. This study aimed to identify smoking-associated immune cell determinants that could guide treatment strategies.

Single-cell RNA sequencing (scRNAseq) was performed on 61 lung tissues from non-smokers and smokers to identify smoking-related immune compositions. The scRNAseq data from 19 invasive lung adenocarcinomas were used to validate their presence in the tumor-immune microenvironment. Bulk RNA sequencing data from 102 resected NSCLC and 24 NSCLC patients treated with neoadjuvant chemoimmunotherapy followed by surgery were used for in silico cellular deconvolution and outcome analyses.

Among 135 lung cellular phenotypes, two natural killer (NK) cell subsets were strongly associated with smoking and chronic obstructive pulmonary disease (COPD) severity. “Stress-responsive” NK (NKSR) cells exhibited immature features and cytokine-responsive features, and “Adaptive and immunoregulatory NK” (NKAIR) cells showed mature features and elevated multiple immune checkpoint expression. High intratumoral NKSR cells correlated with improved survival after surgery, particularly in current smokers. Conversely, tumors with low NKSR and high NKAIR cells responded more favorably to neoadjuvant chemoimmunotherapy.

Intratumoral NK cell phenotyping may aid in therapeutic stratification in patients with NSCLC. NKSR cell preservation predicts benefit from upfront surgery, while NKAIR cell enrichment indicates improved response to neoadjuvant chemoimmunotherapy. These NK cell profiles may help optimize treatment by balancing therapeutic benefit and risk. Central PictureNK cell profiling for treatment stratification in resectable NSCLC Central Message Tumor-infiltrating NK cell profiling identifies distinct immune phenotypes that can inform personalized treatment strategies in resectable NSCLC. Perspective statement Abundance of intratumoral stress-responsive NK cells predicts favorable outcomes after upfront surgery, whereas enrichment of adaptive and immunoregulatory NK cells suggests greater benefit from neoadjuvant chemoimmunotherapy. These findings support incorporating NK-cell profiling into preoperative decision-making to optimize therapy selection and balance risks in the high-risk surgical population. Competing Interest Statement HSL reports research funding from the National Institute of Health, the Department of Defense, the Cancer Prevention Research Institute of Texas, the Helis Medical Research Foundation, and the Dan L. Duncan Comprehensive Cancer Center, as well as investigator-initiated preclinical and clinical research funding from Samyang Biopharm and Momotaro-Gene. BMB reports research funding from the National Institute of Health and Cancer Prevention Research Institute of Texas; clinical trial funding from AstraZeneca, Novartis, and Momotaro-Gene Inc.; and has been a consultant in non-small cell lung cancer for AstraZeneca. RTR reports research support from the National Institutes of Health, the American Association of Thoracic Surgery, and the Gregorio Family Foundation; non-remunerated board of director of the Mesothelioma Applied Research Foundation; was retained to provide expert legal opinion; speaker bureau for Merck. SSG reports a proctor and speaker honoraria from Intuitive Surgical. Other authors have no financial conflict of interest. Footnotes This manuscript was presented at the 105th Annual Meeting of the American Association for Thoracic Surgery. The Institutional Review Board at Baylor College of Medicine (BCM) (H-35782: approval date – 10/22/2021) approved the study protocol and publication of data. The patients provided informed written consent for the publication of the study data. GLOSSARY OF ABBREVIATIONS - COPD - chronic obstructive pulmonary disease - DFS - disease-free survival - GOLD - Global Initiative for Chronic Obstructive Lung Disease - FEV1 - forced expiratory volume in 1 second - FVC - forced vital capacity - HLA - human leukocyte antigen - HR - hazard ratio - IFN-γ - interferon-gamma - ILC - innate lymphoid cell - KIR - killer cell immunoglobulin-like receptor - MHC - major histocompatibility complex - MPR - major pathologic response - NF-κB - nuclear factor-kappa B - NK - natural killer - NKSR - stress-responsive natural killer - NKAIR - adaptive and immunoregulatory natural killer - NSCLC - non-small cell lung cancer - OS - overall survival - PCR - pathological complete response - scRNAseq - single-cell RNA sequencing - TNF-α - tumor necrosis factor-alpha - UMAP - Uniform Manifold Approximation and Projection