From G12C To pan-RAS: The expanding therapeutic landscape of KRAS-mutant NSCLC

KRAS mutations represent the most prevalent oncogenic drivers in non-small cell lung cancer (NSCLC), defining a clinically heterogeneous subset that was historically considered "undruggable." The identification of a mutant-specific allosteric pocket in KRAS G12C led to the development of sotorasib and adagrasib, fundamentally altering the treatment paradigm for pretreated patients. However, modest response durability and the rapid emergence of resistance underscore the limitations of current monotherapies. This review provides a comprehensive synthesis of the expanding therapeutic landscape, moving beyond G12C-selective inhibition toward next-generation allele-specific agents, such as G12D inhibitors, and groundbreaking pan-RAS/RAS(ON) tri-complex inhibitors like RMC-6236. The molecular biology of the KRAS conformational cycle is examined alongside the critical role of co-mutations, specifically STK11, KEAP1, and TP53, which act as gatekeepers of metabolic reprogramming and modulate the tumor immune microenvironment. Furthermore, primary and acquired resistance mechanisms are delineated into on-target pocket alterations and off-target bypass signaling, involving the reactivation of the MAPK and PI3K pathways via RTKs like EGFR and MET. The review also explores the integration of KRAS inhibitors with immune checkpoint blockade, chemotherapy, and SHP2/MEK inhibitors, highlighting a shift toward biology-driven combination strategies. As the field transitions from single-allele blockade to multi-selective RAS(ON) inhibition and rational vertical pathway targeting, personalized, biomarker-guided treatment algorithms will be essential. By outlining the trajectory from G12C to pan-RAS strategies, this review captures the evolving precision oncology framework necessary to achieve durable clinical benefit in KRAS-mutant NSCLC.