FULCRUM CDS
NSCLC — Adenocarcinoma
DEMOJames MorrisonAisha PatelRobert ChenMaria Santos|Enter Real Patient
JM

James Morrison

67 y/o MaleMRN: 0847291NSCLC — AdenocarcinomaEGFR wild-type, ALK negativePD-L1 45%
Stage IIIAWindow closing — act now

Treatment Window

S3 Withdraw
The immune system is withdrawing from the fight. This is the critical decision point. Checkpoint blockade can re-engage the immune response, but the window is closing. Delay significantly reduces response probability.
Critical question: Does the immune system have enough firepower?
If Immune Advantage is above 1.0×, checkpoint blockade can re-engage the retreating immune system. If below 1.0×, ICI alone is unlikely to be sufficient.
▲ HIGH URGENCY — treatment window closing

Immune Advantagei

Likely Responder
2.3×
Immune advantage (adjusted: 2.2×)
Immune system has a clear advantage over tumour proliferation. Checkpoint blockade is structurally indicated.
Structural analysis available
If scRNA-seq data with cell type annotations is available, enter the fractions below for structural drain/signal analysis.
Primary drain
Innate signal
Secondary drain

Step Coverage

2/4 Steps
⚠
Detection
Open
✓
Priming
Carboplatin
✓
Encounter
Pembrolizumab
⚠
Maintenance
Open
AgentStepMechanism
Pembrolizumab—Anti-PD-1 — releases T cell brake
Carboplatin—Platinum — immunogenic cell death creates antigens
Pemetrexed—Antifolate — same priming step as platinum
Open Escape Routes
Detection, Maintenance steps uncovered. Adding a TIGIT inhibitor would NOT help — same Encounter step.

Structural Recommendations

✕

Do not add Pemetrexed

Pemetrexed covers the same step (Priming) as Carboplatin. No additional escape route closed.

?

Consider LAG-3 inhibitor if available

LAG-3 addresses antigen presentation (Detection step) — genuinely different from PD-1.

FULCRUM CDS is a structural analysis tool. It does not replace clinical judgement. Not FDA approved.

Trial Evidence — NSCLC — Adenocarcinoma

Observed ORR
RegimenTrialORRnYear
carbo+pem+pembro_lKEYNOTE-18947.6%4102018
pembro_lKEYNOTE-02444.8%1542016
pembro_lKEYNOTE-042 (all-comers)27.0%6372019
carbo+pemKEYNOTE-189 ctrl18.9%2062018
Source: published Phase II/III trial results. Observed outcomes, not model predictions.

Tumour Immune Profile

GZMB
5.8 log₂
PRF1
5.1 log₂
IFNG
3.9 log₂
GZMA
5.4 log₂
MKI67
6.0 log₂
Immune Adv.
2.3×
Host Drain
IL1B
3.2 log₂
CXCL8
2.8 log₂

Host Capacity

Albumin
3.8 g/dL
NLR
4.2
TMB
12.4 mut/Mb
PD-L1 TPS
45 %

Timeline

Jan 2026
Diagnosis — Stage IIIA NSCLC adenocarcinoma
Feb 2026
NGS panel — EGFR WT, ALK neg, TMB 12.4, PD-L1 45%
Feb 2026
RNA-seq — immune profiling completed
Mar 2026
Treatment decision — FULCRUM CDS consulted
—
Initiate pembrolizumab + carboplatin + pemetrexed
New Patient
SMART on FHIR · FULCRUM v0.2.0 · generativegeometry.science