Reframing tumor bed evaluation in non-small cell lung cancer: histopathological challenges and future directions in the era of neoadjuvant immunotherapy Federica Pezzuto, Eleonora Faccioli, Omar El Mnif, Giuseppe Maggioni, Francesca Lunardi, et al. Frontiers in Oncology, 2026 The introduction of neoadjuvant immunotherapy in non-small cell lung cancer (NSCLC) has led to complex tumor responses that challenge conventional pathological assessment. Thus, traditional endpoints such as major pathological response (MPR) and pathological complete response (pCR) may become insufficient to capture the full spectrum of immune-mediated changes. Indeed, these parameters were originally developed in the context of cytotoxic chemotherapy and may not reflect immune-mediated phenomena and stromal remodeling which can significantly alter the appearance of the tumor bed. As a result, MPR and pCR may underrepresent the true extent of biological response in patients treated with immunotherapy. This review outlines current limitations in morphologic evaluation and highlights the need for immune-adapted criteria. Furthermore, it explores the additional value of digital pathology and AI that offer objective and reproducible quantification of histologic features. Integrating these tools with radiologic and molecular data supports a multidimensional approach to response assessment, aiming to refine prognostication, guide adjuvant therapy, and ensure consistency in clinical trial designs.
Pathologic assessment of resected stage III non-small cell lung cancer after neoadjuvant chemotherapy: identification of additional prognostic factors Francesca Lunardi, Alessandra Ferro, Luca Vedovelli, Federica Pezzuto, Sofia‐Eleni Tzorakoleftheraki, et al. Histopathology, 2026 Background Non‐small cell lung cancer (NSCLC) patients undergoing neoadjuvant chemotherapy (NACT) followed by surgery represent an ideal clinical setting to identify prognostic factors. To date, major pathological response (MPR) and complete pathological response (pCR) have been used as surrogates of NACT response and clinical outcome. The aim of the study was to investigate the role of additional clinico‐pathological features, taking advantage of morphometry and artificial intelligence (AI). Methods Seventy stage III NSCLC patients undergoing surgery after NACT were studied. A granular evaluation of histological parameters with morphometrical quantification of the stromal components (fibrosis/inflammation) in addition to the tumour bed analysis (2020 IASLC statement) was carried out in all cases. An AI algorithm of the different immunophenotypes was also applied on immunohistochemistry‐stained whole‐slide images. A ClinPATH combined score including MPR, baseline blood lymphocytes, perineural invasion, vascular invasion, proliferative index, fibrosis extension percentage and AI‐quantified CD4+ cell % was tested. Results MPR and pCR were related to disease‐free survival (DFS) and overall survival (OS) but also vascular/perineural/pleural invasion and Ki‐67 were useful in stratifying the study population. Concerning the tumour bed stromal components, only morphometrical quantification highlighted the prognostic role of fibrosis and inflammation, particularly when distinguishing CD4+ and FOXP3+ cells, mainly in adenocarcinomas. Interestingly, the combination of the most impactful clinico‐pathological parameters in a ClinPATH combined score correlated better with DFS and OS than any individual parameter, including MPR or pCR. Conclusion AI‐based method can be used to accurately decipher the complexity of tumour bed stromal components, providing extra information for outcome prediction. The combination of different clinico‐pathological features could be highly valuable in guiding therapeutic decisions and ultimately improve patient outcomes.
Long COVID in Immunocompromised and Immunocompetent Patients: A Clinical, Morphologic, and Virologic Portrait Fátima Ramalhosa, Francesca Lunardi, Nicol Bernardinello, Silvia Gori, Federica Pezzuto, et al. Archives of Pathology and Laboratory Medicine, 2025 Context.— Coronavirus disease 2019 (COVID) primarily affects the lung and can lead to chronic/post-COVID syndrome. Some insights about late pulmonary changes occurring in patients recovering from COVID have been published, but the evidence of detailed pathologic changes coming from follow-up care patients with long COVID is limited. Objective.— To evaluate tissue morphologic and viral features in transbronchial biopsies of long COVID patients (immunocompetent and immunocompromised). Design.— This retrospective observational study included 18 patients (9 immunocompetent and 9 immunocompromised) who were consecutively referred to our outpatient clinic for post-COVID pneumonia, undergoing transbronchial biopsy. Several histologic changes were analyzed by computer-assisted morphometric analysis. As organizing pneumonia (OP) was consistently detected, fibrosis and inflammation were also evaluated in transbronchial biopsies from 28 control patients with histologic confirmation of OP. Tissue SARS-CoV-2 and the subgenomic transcripts were investigated. Morphologic findings were correlated with clinical and radiologic data. Results.— Long COVID patients showed lower inflammation than controls ( P < .001) despite a similar fibrotic extension. When considering separately the 2 long COVID groups, the same inflammatory infiltrate extension was found, whereas a higher fibrotic remodeling characterized the immunocompetent subgroup ( P = .05). Molecular investigation showed that SARS-CoV-2 was present in tissue samples obtained from 3 long COVID patients. Conclusions.— Long COVID patients showed a peculiar OP pattern, with more vascular and fibrotic changes. SARS-CoV-2 RNA, even in replicative status, can be detected in lung biopsies of both immunocompetent and immunocompromised patients. This pilot study is a forerunner of more in-depth lung tissue investigations to gain a better understanding of long COVID pathobiology.
Predicting biomarkers of progressive pulmonary fibrosis: morphological, cytokine profile, and clinical portrait Nicol Bernardinello, Federica Pezzuto, Lauren D’Sa, Luca Vedovelli, Chiara Giraudo, et al. Frontiers in Immunology, 2025 ObjectiveThe term progressive pulmonary fibrosis (PPF) refers to a specific disorder that becomes worse despite optimal treatment. The pathogenic explanation of this progressive worsening is still to be found. In this study, we explored whether any histological, molecular, radiological, or clinical features could predict a progressive phenotype in patients with fibrotic interstitial lung diseases.MethodsTwo hundred and fifteen patients with PPF other than idiopathic pulmonary fibrosis (IPF) and connective tissue disease-associated ILD (CTD-ILD) were followed in our ILD clinic between January 2016 and May 2023. Based on tissue block availability, 48 patients were definitively enrolled. Progression was defined according to the most recent guidelines. Clinical, radiological, and functional data were also collected retrospectively and correlated with tissue morphological and molecular cytokine profiles.ResultsFifteen patients were classified as progressors (PPF) and 33 as non-progressors (nPPF) with similar age at diagnosis and gender. PPF showed a higher prevalence of traction bronchiectasis (80% vs. 27%; p=&lt;0.001) at CT scan and lower functional parameters [FVC: 2.42 L vs. 3.37 L; p=0.004; TLC: 3.83 L vs. 4.65 L; p=0.027] at diagnosis. Lung specimens revealed a significant overexpression of IL9 in the PPF compared to the nPPF group (p=0.049). Boruta algorithm analysis showed that lymphoid aggregates and traction bronchiectasis at diagnosis are the most important variables in determining the PPF status.ConclusionsThe present results increase the understanding of the pathological mechanisms of PPF, offering potential avenues for improved prognostication and therapeutic intervention.
Detection of lung allograft injury through a comprehensive multidisciplinary analysis of donor-derived cell-free DNA in plasma and bronchoalveolar lavage: a real-world single center experience Fiorella Calabrese, Federica Pezzuto, Luca Vedovelli, Cecilia De Chellis, Francesca Lunardi, et al. Frontiers in Immunology, 2025 IntroductionPlasma donor-derived cell-free DNA (dd-cfDNA) is an emerging potential tool for diagnosing lung graft injury. This study explored the relevance of dd-cfDNA levels in different graft injuries thoroughly characterized after a well-established multidisciplinary team approach. The usefulness of bronchoalveolar lavage (BAL) dd-cfDNA in complementing detection of allograft injury was also investigated.MethodsPlasma dd-cfDNA was measured by next generation sequence on 127 samples from patients visited consecutively, contemporaneously with a systematic analysis of surveillance transbronchial biopsy by LASHA template, BAL analysis and immunological monitoring.ResultsPatients with immunological injury exhibited the highest plasma dd-cfDNA levels (median 2.67%), with a sensitivity of 100% while patients with non-immunological insults showed a sensitivity of 28%. The combination of BAL with plasma dd-cfDNA improved the sensitivity for detecting non-immunological injury from 28% to 71%. Random forest analysis showed that plasma dd-cfDNA &gt;1% was among the most important variables in predicting death and chronic lung allograft dysfunction.DiscussionOur data suggests that plasma dd-cfDNA is a useful tool for immunological graft injury assessment. The performance of BAL dd-cf DNA needs to be validated on larger case series. The integration of plasma dd-cfDNA with other post-transplant follow-up investigations may allow more sensitive diagnoses and appropriate graft injury management.
Peripheral Circulating Blood Cells Deviation Based on Tumor Inflammatory Microenvironment Activity in Resected Upstaged Lung Adenocarcinomas Alessandro Bonis, Francesca Lunardi, Giulia Pagliarini, Vincenzo Verzeletti, Luigi Lione, et al. Journal of Clinical Medicine, 2024 Background: The tumour inflammatory microenvironment (TIME) reflects a selective activation of the central immune system (IS), particularly T-cells expansion, which leads to immune cells migrating to the target, such as lung cancer, via the bloodstream and lymphatic vessels. In this study, the aim is to investigate whether the distribution of peripheral blood cells varies based on the immune status of patients with lung adenocarcinoma. Methods: This is a single-center retrospective study conducted in the Thoracic Surgery Unit of the University of Padua (Italy) between 1 January 2016 and 1 April 2024. It included patients (>18 years old) with lung adenocarcinoma deemed resectable (cT2bN0M0 or lower) who experienced pathological upstaging (IIB or higher). Patients were classified as TIME-active (with tumour-infiltrating lymphocytes—TILs and/or PD-L1 expression) or TIME-silent (without TILs or PD-L1). According to the TIME status, peripheral blood cell counts with clinical and pathological data were compared between groups using the Fisher’s, Pearson’s or Wilcoxon’s test when appropriate. A Kaplan–Meier estimator investigated overall survival (OS) and recurrence-free survival (RFS) adopting the log-rank test. Results: Preoperatively, the TIME-a group demonstrated a significantly higher lymphocyte count (p = 0.02) and a lower absolute neutrophil rate (p = 0.01) than TIME-s. These differences persisted after resection (p = 0.06 and p = 0.02) while they became similar one month after surgery (p = 1 and p = 0.32). The neutrophil-to-lymphocyte ratio—NLR showed similar trends (p = 0.01 and p = 1). Better OS and RFS were shown in the TIME-a group (p = 0.02 and 0.03, respectively). Conclusions: Resected upstaged lung adenocarcinomas show distinct peripheral blood cell profiles based on immune status. TIME-active patients had a significantly lower NLR, which normalized post-surgery. Surgical resection may help restore native immune surveillance.
