Complementary modes of resistance to EGFR TKI in lung adenocarcinoma through MAPK activation and cellular plasticity

EGFR-mutant lung adenocarcinoma (LUAD) represents 20% of all non-small cell lung carcinomas, with most patients presenting with incurable metastatic disease. Treatment with mutant-selective EGFR tyrosine kinase inhibitors (TKIs) results in initial tumor reduction, yet nearly all patients eventually relapse. The mechanisms driving drug resistance are incompletely understood, creating significant barriers to curing metastatic disease. We integrated clinical genomic and single-nuclei RNA (snRNA) sequencing from a cohort of 62 EGFR-mutant LUAD patients treated with the third generation EGFR TKI, osimertinib, and compared treatment-naive (TN), minimal residual disease (MRD), and progressive disease (PD) tumors. We found that disease progression is associated with a marked decrease in alveolar lineage fidelity, coincident with reduced MAPK signaling and adenocarcinoma identity. PD tumors with sustained MAPK pathway activity, such as those with EGFR or MET amplifications, tended to retain adenocarcinoma identity. In contrast, MAPK-low tumors were more likely to undergo histological transformation to squamous or neuroendocrine lineages. Remarkably, we observed rare tumor cell populations prior to treatment that were poorly differentiated, in some cases with neuroendocrine or squamous features. At progression, these histologically divergent tumor cells increased in prevalence, both in cases with overt histological transformation, and in others with sub-clinical histological plasticity. These findings suggest that pre-existing capacity for histologic plasticity may be a substrate for therapy induced selection. Taken together, our results illuminate genomically encoded MAPK signaling and lineage plasticity as complementary mechanisms of acquired resistance to EGFR TKI in lung adenocarcinoma.