Tumor-infiltrating natural killer cell profiling for therapeutic stratification in patients with resectable non–small cell lung cancer

OBJECTIVE: Neoadjuvant chemoimmunotherapy has improved outcomes in resectable non-small cell lung cancer, yet its real-world implementation is often challenged by surgical delays, immune-mediated fibrosis, and postoperative complications. Smokers with non-small cell lung cancer, despite a high risk for surgical morbidity, show enhanced responses to neoadjuvant chemoimmunotherapy. This study aimed to identify smoking-associated immune cell determinants that could guide treatment strategies. METHODS: Single-cell RNA sequencing was performed on 61 lung tissues from nonsmokers and smokers to identify smoking-related immune compositions. The single-cell RNA sequencing data from 19 invasive lung adenocarcinomas were used to validate their presence in the tumor-immune microenvironment. Bulk RNA sequencing data from 102 patients with resected non-small cell lung cancer and 24 patients with non-small cell lung cancer treated with neoadjuvant chemoimmunotherapy followed by surgery were used for in silico cellular deconvolution and outcome analyses. RESULTS: Among 135 lung cellular phenotypes, 2 natural killer cell subsets were strongly associated with smoking and chronic obstructive pulmonary disease severity. "Stress-responsive" natural killer cells exhibited immature features and cytokine-responsive features, and "adaptive and immunoregulatory natural killer" cells showed mature features and elevated multiple immune checkpoint expression. High intratumoral "stress-responsive" natural killer cells correlated with improved survival after surgery, particularly in current smokers. Conversely, tumors with low "stress-responsive" natural killer and high "adaptive and immunoregulatory natural killer" cells responded more favorably to neoadjuvant chemoimmunotherapy. CONCLUSIONS: Intratumoral natural killer cell phenotyping may aid in therapeutic stratification in patients with non-small cell lung cancer. "Stress-responsive" natural killer cell preservation predicts benefit from up-front surgery, whereas "adaptive and immunoregulatory natural killer" cell enrichment indicates improved response to neoadjuvant chemoimmunotherapy. These natural killer cell profiles may help optimize treatment by balancing therapeutic benefit and risk.