Dissecting the Immune Evasion and Therapeutic Resistance Mechanisms in EGFR/TP53 Co-mutated Non-Small Cell Lung Cancer: Implications for Targeted and Immunotherapy Strategies

Haiyan Shi¹Kun Xu²Xueying Kong¹Weining Xie¹Yingying Chen¹He Ding³Zufu Cheng⁴Xianshan Huo¹Ke Gao¹Mingshuang Song¹Ning Tian^1*

• ¹Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Foshan, China
• ²Shanghai Institute for Biomedical and Pharmaceutical Technologies, Shanghai, China
• ³Shanghai Labway Clinical Laboratory, Shanghai, China
• ⁴Guangzhou Laboratory, Guangzhou, China

Background: Although precision-targeted therapies and tyrosine kinase inhibitors (TKIs) have significantly improved outcomes in non-small-cell lung cancer (NSCLC), patients with EGFR-mutant NSCLC with concurrent TP53 mutations often develop drug resistance and experience poor clinical outcomes. This study aims to investigate the molecular mechanisms underlying this aggressive subtype using single-cell RNA sequencing. Methods: Formalin-fixed paraffin-embedded (FFPE) tumor samples were obtained from 40 hospitalized NSCLC patients. Somatic mutation profiles were determined using a targeted 23-gene next-generation sequencing (NGS) panel. Four samples harboring concurrent EGFR and TP53 mutations were selected for single-cell transcriptomic profiling using the 10x Genomics platform. Results: Two dominant malignant epithelial cell populations were identified: C1_EGFR⁺, associated with proliferation and invasion, and C2_STAT1⁺, linked to immunosuppression and drug resistance. These tumor subtypes cooperatively drive CD8⁺ T cell exhaustion through the MDK-(ITGA4+ITGB1), MIF-(CD74+CXCR4), and TGF-β signaling pathways.In addition, antigen-presenting cancer-associated fibroblasts (apCAFs) recruit regulatory T cells via the CCL5-CCR4 axis, collectively establishing an immuneexcluded tumor microenvironment. Mechanistically, a STAT1/ETS1-centered transcriptional program regulates the expression of key immunosuppressive (e.g., MDK, MIF, TGFB1) and resistance-associated genes (e.g., ERBB2, JAK2). Conclusion:These findings reveal a coordinated transcriptional network that promotes immune evasion and therapeutic resistance in EGFR/TP53 co-mutated NSCLC. Targeting the STAT1/ETS1 axis, in combination with EGFR-TKIs or immune checkpoint inhibitors, may provide a novel strategy to overcome resistance and improve patient outcomes.Further validation in larger patient cohorts and functional studies is warranted to confirm these observations and support clinical translation.