Postoperative re-profiling for identification of missed drivers and a high-risk fusion subgroup in non-pCR lung adenocarcinoma after neoadjuvant immunotherapy: A multicenter retrospective study.

8064 Background: For stage II-III driver-negative non–small cell lung cancer (NSCLC), neoadjuvant chemoimmunotherapy followed by surgery is standard. However, patients without pathological complete response (non-pCR) have suboptimal outcomes and heterogeneous benefit from adjuvant immunotherapy. Baseline driver-negative status may be confounded by false-negative PCR- or DNA-only testing and detecting missed drivers postoperatively could alter adjuvant strategies. This study characterized post-treatment driver alterations and its prognostic value in non-pCR NSCLC after neoadjuvant immunotherapy. Methods: The retrospective multicenter study enrolled 247 stage II-III lung adenocarcinoma (LUAD) patients initially tested as EGFR L858R/19del- and ALK-negative and treated with neoadjuvant immunotherapy (2018-2025). 76 lung squamous cell carcinoma (LUSC) cases were included for exploratory analysis. Postoperative samples underwent 35-gene synchronous DNA/RNA next-generation sequencing (DR-NGS) to identify SNV/indel and fusion events and assess prognostic associations. Results: Of 247 LUAD cases, 179 passed NGS quality control (QC). Driver alterations were identified in 104 (58.1%) patients, including 26 fusions: RETn = 9), MET ex14 skipping (n = 6), ALK(n = 4), ROS1(n = 3), NRG1(n = 2), MET fusion(n = 1), NTRK(n = 1) and 80 SNVs/indels :EGFR (n = 30), KRAS G12C/D (n = 16), HER2/3 (n = 16), BRAF (n = 2), KRAS non-G12C/D (n = 16). Notably, 10 classic EGFR mutations (19del/L858R) 、9 rare EGFR mutations and 4 ALK fusions were newly identified, indicating baseline omissions. Driver-positive tumors had significantly higher residual tumor burden(median: 51.8% vs. 35.8%, p = 0.003) and a higher proportion of females (43.3% vs 20.0%, p = 0.001). Median recurrence-free survival (mRFS) differed significantly among fusion-positive, mutation-positive, and driver-negative groups (20.9 vs 41.5 vs 60.3 months; p = 0.024). In patients receiving adjuvant immunotherapy, mRFS was 34.6 months in driver-positive and not reached in driver-negative patients. Driver detection was rare ( < 3%) in QC-failed samples (n = 68), which exhibited a higher major pathological response than QC-passed samples (58.1% vs 14.5%), indicating tumor cellularity as critical for detection. Exploratory analysis in 55 QC-passed LUSC samples showed a low driver detection rate (7.3%), suggesting limited utility in this cohort. Conclusions: DR-NGS reveals a high prevalence of drivers in non-pCR LUAD after neoadjuvant immunotherapy, with positivity associated with higher residual tumor burden. Fusion-positive patients have the poorest prognosis, identifying a subgroup that may benefit from tailored adjuvant strategies. These findings support routine postoperative molecular re-profiling in non-pCR patients to guide individualized treatment.