近年来，在非小细胞肺癌（NSCLC）患者中，靶向治疗的分子诊断取得了显著的提高。在这里，我们报告了NSCLC罕见融合基因的患病率，并解析了其基因组结构和潜在的临床意义。总共，n = 5554例NSCLC患者进行了下一代测序（NGS）来同时检测癌基因突变和融合基因，其中主要诊断时进行了检测（n = 5246例），或在治疗抗药性出现后进行了检测（n = 308例）。我们采用了不同尺寸的基因检测面板，包括闭合式扩增子和开放式扩增子的应用，例如锚定多重PCR（AMP）和基于杂交捕获的应用，以检测包括“罕见”融合基因在内的易感突变，定义为在ALK、ROS1、RET以外的NSCLC中频率小于0.5%的融合基因。在0.5%（n = 26例）的治疗前肿瘤和2%（n = 6例）的TKI治疗肿瘤中检测到涉及EGFR、MET、HER2、BRAF和其他潜在可行的癌基因的罕见融合基因。使用开放式扩增子和/或较大的基因检测面板，特别是覆盖超过25个基因的面板，检测率约提高1-2%（p = 0.001）。患者特征（年龄，性别，吸烟，TP53共突变（56%）或平均肿瘤突变负荷（TMB）（4.8个突变/Mb））与罕见融合基因的存在无关。在检测到的罕见融合基因中，非功能性改变，即框外或缺乏激酶结构域，占了三分之一，并与同时存在的典型癌基因驱动子（如EGFR或KRAS突变）（p < 0.001）或使用更大的基因检测面板有显著关联（在25个以上的基因中，非功能性在检测到的罕见融合基因中的频率为57%，而较小的面板中为12%，p < 0.001）。许多罕见融合基因在可获得靶向治疗之前就已经被识别出来，而治疗前患者的平均生存期为23.8个月，与野生型肿瘤相当。约1-2%的晚期NSCLC患有罕见融合基因，这些融合基因具有潜在的可行性，并可能支持诊断。在晚期NSCLC中，常规采用广泛的NGS检测方法能够识别出确切的融合点和潜在保留的蛋白质结构域，从而增加了治疗相关的分子信息的获取率。版权所有© 2023 Elsevier B.V. 保留所有权利。

Molecular diagnosis for targeted therapies has been improved significantly in non-small-cell lung cancer (NSCLC) patients in recent years. Here we report on the prevalence of rare fusions in NSCLC and dissect their genomic architecture and potential clinical implications.Overall, n = 5554 NSCLC patients underwent next-generation sequencing (NGS) for combined detection of oncogenic mutations and fusions either at primary diagnosis (n = 5246) or after therapy resistance (n = 308). Panels of different sizes were employed with closed amplicon-based, or open assays, i.e. anchored multiplex PCR (AMP) and hybrid capture-based, for detection of translocations, including "rare" fusions, defined as those beyond ALK, ROS1, RET and <0.5 % frequency in NSCLC.Rare fusions involving EGFR, MET, HER2, BRAF and other potentially actionable oncogenes were detected in 0.5% (n = 26) of therapy-naive and 2% (n = 6) TKI-treated tumors. Detection was increased using open assays and/or larger panels, especially those covering >25 genes, by approximately 1-2% (p = 0.001 for both). Patient characteristics (age, gender, smoking, TP53 co-mutations (56%), or mean tumor mutational burden (TMB) (4.8 mut/Mb)) showed no association with presence of rare fusions. Non-functional alterations, i.e. out-of-frame or lacking kinase domains, comprised one-third of detected rare fusions and were significantly associated with simultaneous presence of classical oncogenic drivers, e.g. EGFR or KRAS mutations (p < 0.001), or use of larger panels (frequency of non-functional among the detected rare fusions 57% for 25+ gene- vs. 12% for smaller panels, p < 0.001). As many rare fusions were identified before availability of targeted therapy, mean survival for therapy-naïve patients was 23.8 months, comparable with wild-type tumors.Approximately 1-2% of advanced NSCLC harbor rare fusions, which are potentially actionable and may support diagnosis. Routine adoption of broad NGS assays capable to identify exact fusion points and potentially retained protein domains can increase the yield of therapeutically relevant molecular information in advanced NSCLC.Copyright © 2023 Elsevier B.V. All rights reserved.