Association of BAL Fluid T-Cell Immune Activity With Tumor PD-L1 Expression and Its Prognostic Value: A Prospective Observational Study

Tumor PD-L1 expression assessed by immunohistochemistry on tumor tissue specimens is an established biomarker for selecting immune checkpoint inhibitor therapy in lung cancer; however, its clinical utility is limited by intratumoral heterogeneity, temporal variability, and dependence on the size and location of tissue biopsy samples. As a result, tissue-based PD-L1 expression alone does not fully capture the immune context of the tumor microenvironment or reliably predict treatment response and prognosis in all patients.

Bronchoalveolar lavage fluid provides access to the local pulmonary immune microenvironment and contains immune cells that may reflect tumor-immune interactions more directly than peripheral blood. Prior studies suggest that T-cell populations in bronchoalveolar lavage fluid share phenotypic characteristics with tumor-infiltrating lymphocytes and may serve as surrogate indicators of local antitumor immune activity. However, the relationship between bronchoalveolar lavage T-cell immunophenotypes, tissue-based tumor PD-L1 expression, and clinical outcomes has not been comprehensively evaluated in a prospective setting.

This single-center prospective observational cohort study enrolls adult patients with suspected or confirmed stage IV lung cancer who are undergoing clinically indicated bronchoscopy as part of routine diagnostic or management procedures. Residual bronchoalveolar lavage fluid obtained during standard-of-care bronchoscopy is analyzed using multicolor flow cytometry to quantify T-cell subsets, including activated, exhausted, and regulatory populations defined by surface marker expression. Tumor PD-L1 expression is evaluated by immunohistochemistry performed on diagnostic tumor tissue specimens obtained as part of routine clinical care and analyzed both as a continuous variable and by predefined expression categories.

Participants receive standard systemic anticancer therapy according to current clinical guidelines, including immune checkpoint inhibitor-based regimens when indicated. Clinical outcomes, including objective response rate, progression-free survival, and overall survival, are prospectively collected from electronic medical records. The study examines correlations between bronchoalveolar lavage T-cell immunophenotypes and tissue-based tumor PD-L1 expression, as well as whether stratification based on combined immune profiling provides improved prognostic information compared with tumor PD-L1 expression alone.

By integrating local immune profiling from bronchoalveolar lavage fluid with tumor PD-L1 expression assessed in tissue specimens, this study seeks to identify complementary biomarkers that may enhance risk stratification and refine prognostic assessment in advanced lung cancer, potentially informing future approaches to personalized immunotherapy.

Primary outcomes

• Correlation Between Bronchoalveolar Lavage T-cell Immunophenotypes and Tumor PD-L1 Expression [At baseline, prior to initiation of systemic anticancer therapy]: The primary outcome is the association between T-cell immunophenotypes quantified in bronchoalveolar lavage fluid by multicolor flow cytometry and tumor PD-L1 expression assessed by immunohistochemistry. T-cell subsets include activated, exhausted, and regulatory T-cell populations defined by surface marker expression (e.g., PD-1, TIM-3, CD39, CD28, CD25, and CD127). Tumor PD-L1 expression is evaluated as the percentage of PD-L1-positive tumor cells and analyzed as a continuous variable and by predefined categories (<1%, 1-49%, ≥50%).

Secondary outcomes

• Differences in Bronchoalveolar Lavage T-cell Immunophenotypes Across Tumor PD-L1 Expression Categories [At baseline, prior to initiation of systemic anticancer therapy]: This outcome compares bronchoalveolar lavage T-cell subset distributions among participants stratified by tumor PD-L1 expression categories (<1%, 1-49%, and ≥50%). T-cell immunophenotypes are assessed by flow cytometry and include proportions of activated, exhausted, and regulatory T-cell subsets.
• Objective Response Rate by Combined Tumor PD-L1 Expression and Bronchoalveolar Lavage T-cell Immunophenotypes [From treatment initiation to first radiologic response assessment (typically 6-12 weeks)]: Objective response rate is defined as the proportion of participants achieving complete or partial response according to RECIST version 1.1. Objective response rates are evaluated using combined stratification by tumor PD-L1 expression categories and bronchoalveolar lavage T-cell immunophenotype profiles, and compared with response rates stratified by tumor PD-L1 expression alone to assess improvement in treatment response prediction.
• Progression-Free Survival by Combined Tumor PD-L1 Expression and Bronchoalveolar Lavage T-cell Immunophenotypes [From treatment initiation to disease progression or death, up to approximately 24 months]: Progression-free survival is defined as the time from initiation of systemic anticancer therapy to disease progression or death from any cause, whichever occurs first. Progression-free survival is analyzed using combined stratification based on tumor PD-L1 expression categories (<1%, 1-49%, ≥50%) and bronchoalveolar lavage T-cell immunophenotype profiles. Survival outcomes using the combined stratification are compared with those based on tumor PD-L1 expression categories alone to evaluate the incremental prognostic value of bronchoalveolar lavage immune profiling.
• Overall Survival by Combined Tumor PD-L1 Expression and Bronchoalveolar Lavage T-cell Immunophenotypes [From treatment initiation to death from any cause, up to approximately 24 months]: Overall survival is defined as the time from initiation of systemic anticancer therapy to death from any cause. Overall survival is analyzed according to combined stratification by tumor PD-L1 expression categories and bronchoalveolar lavage T-cell immunophenotype profiles. Survival outcomes derived from the combined model are compared with those based on tumor PD-L1 expression alone to assess whether bronchoalveolar lavage immune profiling improves prognostic discrimination.

Sex: All, ages: 19 Years to any

Inclusion Criteria:

* Adults aged 19 years or older
* Patients with suspected or histologically confirmed stage IV lung cancer based on clinical and radiologic findings
* Scheduled to undergo clinically indicated bronchoscopy with bronchoalveolar lavage as part of routine clinical care
* Able and willing to provide written informed consent

Exclusion Criteria:

* Receipt of treatment for acute lower respiratory tract infection (including pneumonia or fungal infection) within 4 weeks prior to bronchoscopy
* History of solid organ transplantation or hematopoietic stem cell transplantation
* Current use of systemic immunosuppressive therapy
* Current or planned use of biologic immunomodulatory agents
* Known autoimmune disease requiring systemic immunosuppressive treatment
* Pregnant women
* Patients with recurrent stage IV lung cancer after prior definitive therapy

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