Impact of metabolic and nutritional disorders on the synergy between radiotherapy and immunotherapy in non-small-cell lung cancer.

Background: Patient conditions including metabolic and nutritional status were reported to be prognostic or predictive biomarkers of anti-cancer treatment, while little attention has been paid to its association with the synergistic effect of radiotherapy (RT) and immune checkpoint inhibitors (ICIs).

Methods: Metastatic non-small-cell lung cancer (mNSCLC) patients who received concurrent RT and ICIs between 2018 and 2023 were included in this study. In addition, mNSCLC patients treated with ICIs alone were enrolled to confirm the synergetic effect of RT and ICIs. Clinicopathological, metabolic and nutritional factors were collected to analyze their influence on progression-free survival (PFS), overall survival and abscopal control time. Abdominal CT was used to obtain body composition data including abdominal obesity and muscle mass.

Results: A total of 96 mNSCLC patients who received RT concurrent with ICIs were included, and a synergistic effect of significantly improved PFS was observed when compared with patients treated with ICIs alone. Among patients undergoing concurrent RT and ICIs, both total adipose area(HR = 2.81,P = 0.029) and prognosis nutritional index (HR = 0.24, P<0.001) were confirmed as independent positive prognostic markers for PFS. Later-line of immunotherapy (HR = 3.67, P = 0.006), low visceral-to-subcutaneous ratio (VSR, HR = 5.53, P = 0.002), high total adipose area (HR = 5.21, P = 0.0016) and high prognostic nutritional index (HR = 0.24, P = 0.002) were independent risk factors for abscopal progression. Then, we established a scoring system consisting of metabolic and nutritional factors to stratify patients into three groups. Patients with non-visceral obesity and good nutrition status have the longest PFS and abscopal control survival, while patients with poor nutritional status regardless of body composition represent the worst prognosis.

Conclusion: Metabolic and nutritional status, particularly the combined assessment of body composition and nutritional index, serves as a valuable predictor for the synergistic efficacy of concurrent RT and ICIs.