Fluid phase biopsy (circulating tumour DNA and serum tumour markers) in
patients with non-small cell lung cancer.

Levels of serum tumour markers and circulating tumour DNA (ctDNA) in plasma
could reflect the clinical course of disease and its response to treatment in
patients with locally advanced NSCLC treated with concurrent chemoradiotherapy
and in patients with stage IV disease treated with systemic therapy. In
addition, identification of molecular pathways activated in NSCLC could provide
targets for new treatments and/or
guide current treatment options.

In advanced NSCLC & in first stage of study in locally advanced NSCLC:
To assess the kinetics of STMs and ctDNA in plasma before, during and after
treatment for NSCLC.

Second stage of study in locally advanced NSCLC:
To determine the prognostic value of change in ctDNA levels during treatment
with regard to treatment response in patients with (locally) advanced NSCLC
(early response marker).

Plasma samples will be collected prospectively before, during and after
treatment. Besides, ctRNA will be isolated from blood platelets from a subset
of patients with a know/suspected translocation. Both patients with locally
advanced NSCLC and with advanced NSCLC can be included in the study. For
patients with locally advanced NSCLC, the study involves two stages that will
be performed consecutively. The first stage is explorative in nature assessing
the biological variation in the quantity of mutations in ctDNA and the
biological variation in STM throughout treatment.

The data collected in this first study stage will help to determine the optimal
collection points for the second study stage, which is a validation phase
testing the value of ctDNA and STMs as early response marker. The second stage
will only be initiated once the first stage is completed successfully. Upon
disease progression, patients will be asked to have a tumor biopsy (optional
part of the study).

Extra blood will be drawn only at regularly planned blood drawls. For patients
with locally advanced NSCLC in the first stage of this study this will be: once
before start of treatment (16 ml), at ten different moments during treatment
(each drawl 8 ml blood and only once 16 ml) and at maximally five moments after
end of treatment (16ml each). In the second stage of this study the number of
blood drawls during treatment will be reduced to a maximum of three, the exact
amount of blood to be drawn in this second study stage will be determined after
completion of the first study stage. For patients with advanced stage NSCLC,
blood will be drawn (16 ml) at baseline, 3-weekly during treatment and 6-weekly
after treatment until disease progression.

It is optional to take a tumour biopsy at disease progression. Patients may
have discomfort due to taking biopsies. Biopsies will be taken from metastases
that are easily accessible (mainly subcutaneous and lymph node metastases) and
will be performed by means of ultrasound guidance by an experienced
radiologist.

In this study, tumor and germline DNA will be analyzed using sequencing
techniques. Therefore, there is a small possibility of detection of unsolicited
findings, i.e. germline DNA variants that confer an increased risk of
developing malignancies or other diseases both for the patient and his/her
family. Patients should be informed and offered genetic counselling in case of
revelation of a variant that is clinically relevant and medically actionable.
However, the analysis of ctDNA / ctRNA is not part of an established workflow
and methods have not been validated yet. Therefore, it is not realistic to
expect that reporting of the data to the patient will take place in the present
trial. The patient information form will be adapted to allow described
counselling and to prevent too high expectations.