Multicenter, Single-Arm, Prospective Phase II Study of Neoadjuvant Cryo-Thermal Ablation Combined With Toripalimab and Chemotherapy for Resectable Stage IB-IIIB Non-Small Cell Lung Cancer (NEOCTATC)

Participants will receive CT-guided Cryo-Thermal Ablation followed by 3 planned cycles of toripalimab plus histology-appropriate platinum-based doublet chemotherapy administered every 3 weeks, followed by curative-intent surgical resection after preoperative reassessment.

Cryo-Thermal Ablation is a CT-guided percutaneous local ablation procedure performed on the primary lung tumor before initiation of neoadjuvant systemic therapy. Under CT guidance, one or more ablation probes are placed percutaneously into the target lesion. Sequential cryogenic and thermal treatment is delivered according to the study protocol and device operating instructions. Technical parameters, including probe placement, treatment cycles, treatment duration, and target temperatures, will be standardized according to the protocol.

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Toripalimab, an anti-programmed cell death protein 1 (PD-1) monoclonal antibody, will be administered intravenously at a dose of 240 mg every 3 weeks (q3w) in combination with platinum-based doublet chemotherapy for 3 planned cycles following Cryo-Thermal Ablation. Dose interruption, delay, or discontinuation will be permitted when clinically indicated for treatment-related toxicity.

Participants will receive protocol-specified platinum-based doublet chemotherapy in combination with toripalimab every 3 weeks for 3 planned cycles following Cryo-Thermal Ablation. The specific regimen will be selected according to tumor histology and the study protocol. Chemotherapy dosing, administration, dose modification, and supportive treatment will follow the protocol-defined regimen and standard clinical practice. After neoadjuvant therapy, disease reassessment will be performed before curative-intent surgical resection.

The proportion of enrolled participants who achieve pathological complete response (pCR), defined as no residual viable tumor cells in the resected primary tumor and all sampled regional lymph nodes after neoadjuvant treatment (ypT0N0).

Participants who do not undergo surgical resection or for whom pathological response cannot be adequately assessed will not be considered to have achieved pCR in the primary efficacy analysis.

The proportion of enrolled participants who achieve a complete response (CR) or partial response (PR) as their radiographic tumor response before surgery, as assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1.

The proportion of enrolled participants who achieve major pathological response (MPR), defined as ≤10% residual viable tumor cells within the primary tumor bed in the resected lung specimen after neoadjuvant treatment, based on pathological assessment according to IASLC recommendations.

Pathological response in regional lymph nodes will be assessed and reported separately and will not be included in the primary definition of MPR.

The proportion of participants undergoing surgical resection who achieve an R0 resection, defined as complete macroscopic resection of the tumor with microscopically negative surgical margins and no residual tumor at the resection margins.

Event-free survival (EFS) is defined as the time from enrollment to the first occurrence of any of the following events: radiographic disease progression; local disease progression resulting in unresectability; inability to undergo the planned curative-intent surgery because of treatment-related toxicity or deterioration in clinical condition attributable to study treatment; failure to achieve tumor resection because of intraoperative unresectability; local or distant disease recurrence after surgery; or death from any cause. Participants without an EFS event will be censored at the date of the last disease assessment.

Overall survival (OS) is defined as the time from enrollment to death from any cause. Participants who are alive at the time of analysis will be censored at the date they were last known to be alive.

Health-related quality of life will be assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). The Global Health Status/Quality of Life scale is transformed to a score ranging from 0 to 100, with higher scores indicating better overall health status and quality of life. Changes from baseline will be evaluated across predefined perioperative assessment time points.

The proportion of participants who experience one or more treatment-emergent adverse events (TEAEs). Adverse events will be assessed for type, severity, and relationship to study treatment and graded according to NCI-CTCAE version 5.0. Safety assessments will include events associated with Cryo-Thermal Ablation, neoadjuvant chemoimmunotherapy, and the perioperative treatment course.

Atera In Situ single-cell spatial transcriptomic profiling will be performed on FFPE tumor specimens. Within-participant changes from the baseline tumor biopsy before Cryo-Thermal Ablation to the surgical tumor specimen after neoadjuvant chemoimmunotherapy will be evaluated. Spatial immune features in the surgical specimen will also be compared among residual tumor, adjacent tissue, and normal lung tissue when available. Analyses will characterize spatial distributions and transcriptional states of CD8+ T cells, regulatory T cells, myeloid populations, interferon-related signaling, antigen-presentation pathways, and T-cell activation/exhaustion programs. Features will also be compared between participants with and without MPR; pCR will be explored as a subgroup.

Bulk T-cell receptor sequencing (TCR-seq) will be performed on peripheral blood mononuclear cells and tumor tissue to characterize treatment-associated T-cell clonal dynamics. Peripheral blood will be collected at baseline before Cryo-Thermal Ablation, approximately 14 days after ablation before Cycle 1, before Cycles 2 and 3 of neoadjuvant chemoimmunotherapy, and after completion of neoadjuvant therapy before surgery. TCR repertoire diversity, clonality, and clonal expansion will be evaluated longitudinally. Tumor tissue from the baseline biopsy and surgical resection specimen will also undergo TCR-seq. Changes in intratumoral T-cell clonality and overlap between blood and tumor TCR clonotypes will be explored in relation to pathological response and treatment-related toxicity.

Baseline FFPE tumor biopsy specimens will undergo next-generation sequencing using a 919-gene cancer-associated panel. Somatic genomic alterations, including relevant mutations and other detectable genomic features, will be characterized. Exploratory analyses will evaluate associations between baseline tumor genomic characteristics and pathological response to Cryo-Thermal Ablation combined with neoadjuvant chemoimmunotherapy.

Circulating tumor DNA (ctDNA) will be longitudinally assessed to characterize changes in tumor-derived molecular signals during treatment and postoperative surveillance. During neoadjuvant treatment, ctDNA levels and detectable tumor-associated alterations will be evaluated at baseline before ablation, 14 days after ablation, and at the preoperative assessment after completion of neoadjuvant therapy. ctDNA clearance and changes in variant allele abundance will be explored according to pathological response. Serial postoperative ctDNA testing will be used to assess molecular residual disease (MRD) and its relationship with subsequent disease recurrence. Longitudinal ctDNA profiles will also be explored for changes in detectable tumor clones over time.

Imaging Mass Cytometry (IMC) will be performed on selected FFPE surgical tumor specimens after neoadjuvant treatment as an orthogonal protein-level validation of spatial immune findings. Analyses will quantify selected immune cell populations and protein markers, including CD8+ T cells, regulatory T cells, myeloid populations, PD-L1, antigen-presentation markers, and markers of immune activation or proliferation such as granzyme B (GZMB) and Ki-67. Spatial relationships between immune cells and tumor cells, including immune-cell density, cellular proximity, and tumor-immune spatial organization, will be compared between participants with MPR and those without MPR. pCR cases will be explored as a subgroup where evaluable tissue is available.

Tumor or tumor-bed specimens obtained at surgical resection will undergo metagenomic sequencing to characterize the intratumoral microbiome. The relative abundance of detected microbial taxa will be quantified and reported as the percentage of the total microbial abundance represented by each taxon. Microbial relative abundance profiles will be compared between participants with major pathological response (MPR) and those without MPR. Pathological complete response (pCR) cases will be explored as a subgroup when tumor-bed specimens are technically evaluable.

Tumor or tumor-bed specimens obtained at surgical resection will undergo metabolomic profiling to characterize intratumoral metabolic features. Detected metabolites will be quantified using normalized metabolite abundance, expressed as normalized signal intensity in arbitrary units. Metabolite abundance profiles will be compared between participants with major pathological response (MPR) and those without MPR. Pathological complete response (pCR) cases will be explored as a subgroup when tumor-bed specimens are technically evaluable.