Sonya Hessey, Abigail Bunkum, Ariana Huebner, Kerstin Haase, Kristiana Grigoriadis, Cristina Naceur-Lombardelli, Wing Kin Liu, Caitlin F. Harrigan, Charlotte Grieco, Daniele Marinelli, Boyue Ding, Carlos Martínez-Ruíz, Piotr Pawlik, Mark S. Hill, Olivia Lucas, Corentin Richard, Oriol Pich, Kerstin Thol, Takahiro Karasaki, Sophia Ward, Foteini Athanasopoulou, Monica Sivakumar, Selvaraju Veeriah, Antonia Toncheva, Andrew J. Rowan, Paulina Prymas, Hayley Bridger, Miriam Mitchison, Elaine Borg, Mary Falzon, Ian Proctor, Ula Mahadeva, A Green, Martin D Forster, Sarah Benafif, Tanya Ahmad, Siow Ming Lee, Dionysis Papadatos-Pastos, Babu Naidu, Gerald Langman, Matthew Krebs, Pedro Oliveira, Fiona Blackhall, Yvonne Summers, Jamie Weaver, J. Le Quesne, Anne Thomas, C Richards, Dean A Fennell, Sanjay Jogai, Judith Cave, Patricia Roxburgh, Sioban Fraser, Alan Kirk, Kevin G Blyth, Peter Russell, Crispin T. Hiley, Allan Hackshaw, John Le Quesne, Jason F. Lester, Amrita Bajaj, Apostolos Nakas, Azmina Sodha-Ramdeen, Claire Wilson, M Scotland, Rebecca Boyles, Sean Dulloo, Sridhar Rathinam, Gurdeep Matharu, Jacqui A. Shaw, Ekaterini Boleti, Heather Cheyne, Gillian Price, Keith M. Kerr, Mohammed Khalil, Shirley Richardson, Tracey Cruickshank, Jack French, Kayleigh Gilbert, Akshay Patel, Aya Osman, Gary Middleton, Helen Shackleford, Madava Djearaman, Mandeesh Sangha, A E Leek, Adam Atkin, Anshuman Chaturvedi, António Paiva‐Correia, C C LINDSAY, Eustace Fontaine, Felice Granato, Jack Davies Hodgkinson, Juliette Novasio, Katherine D. Brown, Kandadai Rammohan, Leena Joseph, Mathew Carter, Nikki Totton, Paul Bishop
. Here, using 501 longitudinally collected primary and metastatic tumour samples from 24 patients with non-small cell lung cancer (NSCLC) enrolled in the TRACERx lung study and PEACE autopsy programme, we infer tumour evolution from diagnosis to death. With DNA-sequencing data encompassing 70% of the metastases that were radiologically detected before death and paired multi-region sampled primary tumours, we show that the genomes of metastases diverge markedly from those of their ancestral primary tumour, with additional driver alterations and genome doubling events occurring after metastatic dissemination. In 62.5% of patients, multiple primary tumour subclones disseminated, each founding a distinct metastasis. These metastases served as sources of onward spread: more than half of the metastases sampled were seeded by other metastases. The duration that metastases existed in situ influenced their likelihood of seeding further metastases. Most metastatic migrations started and ended in the same anatomical cavity. The few subclones that exited the thorax to seed metastases disseminated widely and were enriched for somatic copy-number alterations, suggesting that chromosomal instability may facilitate extrathoracic spread. This spatial and temporal evolutionary analysis sheds light on the extent of metastatic diversity and seeding in advanced NSCLC-which tends to be underestimated in single metastasis biopsies-and identifies genomic and clinical mediators of metastatic progression.