Introduction
Methodology
Literature review and definition of clinical scenarios for discussion
First round of voting
Communicating the results and second round of voting
Definition of conclusions in nominal group meeting
Results
Molecular diagnosis and biomarkers
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Molecular diagnosis and biomarkers PD-L1 expression and EGFR mutation should always be evaluated in initial biopsy It is reasonable to perform ALK translocation, KRAS mutation and ROS 1 translocation studies if there is availability to offer neoadjuvant targeted therapy in a clinical trial setting A comprehensive genomic profiling study can be considered only if there is administrative/logistical availability to obtain it shortly Radiological diagnosis Thoracoabdominal CT with contrast including supraclavicular region, thorax, and upper abdomen should always be performed PET-CT should always be performed Brain MRI with contrast should be indicated to complete the staging. If brain MRI it is no available, it is reasonable perform brain TC with contrast Cervicothoracic MRI may be considered in some cases of Pancoast tumors with suspected infiltration of mediastinal structures Surgical diagnosis and mediastinal staging The following indications for mediastinal staging should be considered: Presence of central airway tumor Finding of enlarged hilar or mediastinal lymph nodes on CT scan or with elevated/pathologic SUV on positron emission tomography (PET- CT) Mediastinal diagnosis/staging should be performed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) or endobronchial ultrasound-guided fine-needle aspiration (EUS-FNA) in a center with extensive experience in this type of technique It is reasonable to perform surgical exploration of the mediastinum with the most efficient technique defined by the multidisciplinary group (mediastinoscopy, video thoracoscopy, etc.) if EBUS or EUS did not obtain satisfactory results, or it was not possible to perform them and there is strong suspicion of lymph node involvement |
Radiological diagnosis
Surgical diagnosis and mediastinal staging
Role of the thoracic multidisciplinary committee
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Role of the multidisciplinary thoracic committee The multidisciplinary thoracic committee should be constituted by pathologists, radiologist, nuclear medicine specialists, pulmonologists, palliative care and oncology support specialists, thoracic surgeons, radiation oncologists and medical oncologists A case manager should be available to support the administrative and logistics management required for the performance of the diagnostic procedures and treatments defined by the multidisciplinary thoracic committee According to possibility of each health institution, it is reasonable that other professionals involved in the care of lung cancer patients also participate in the thoracic committee Clinical situations in which patients should be discussed in the multidisciplinary thoracic committee include: All patients with stage III disease At diagnosis with results of extension images to evaluate the possibility of definitive surgical management and the option of administering neoadjuvant and/or sequence of treatment In complex cases or with difficulty in defining the technique for taking a biopsy Define the invasive mediastinal staging technique (EBUS-TBNA, EUS-FNA, mediastinoscopy or other surgical technique) After neoadjuvant treatment with post-treatment control imaging results to evaluate tumoral response and define surgical treatment After surgical treatment to review the anatomic pathology report and define the need for additional/adjuvant interventions |
Neoadjuvant treatment
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For radiologic evaluation, the imaging studies to be performed after completion of neoadjuvant treatment should include a chest CT scan with contrast-enhanced upper abdomen compared to the baseline study and should include response measurement according to RECIST criteria [89]. In addition, the presence of distant disease should be evaluated with a PET-CT [90, 91]. It was suggested that additional imaging should be performed only in cases of de novo symptoms and/or tumor progression, and that histologic confirmation should be performed in all cases of suspected tumor progression whenever technically feasible.
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Regarding mediastinal restaging after neoadjuvant treatment, it was felt that it should only be performed if there is doubt about the tumor response on imaging. There are studies showing that when endoscopic techniques such as EBUS-TBNA are used after induction treatment, the NPV varies from 20 to 78%, indicating a high variability in efficacy [92, 93]. While there is information regarding mediastinoscopy in patients after induction therapy, it is less sensitive than the primary procedure due to the presence of adhesions and fibrotic tissue [94‐96].
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In terms of evaluating tumoral response and to consider patient with resectable tumor, it was agreed that the criteria for resectability after neoadjuvant treatment should include:
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Neoadjuvant treatment Neoadjuvant treatment with platinum-based doublet of chemotherapy plus immunotherapy should be offered to all patients with potentially resectable NSCLC, unless the patient have absolute contraindications for immunotherapy and regardless of PD-L1 expression Considerations for neoadjuvant treatment The possibility of resectability and benefit of neoadjuvant treatment should be considered at diagnosis in a multidisciplinary committee meeting After completion of neoadjuvant treatment, the possibility of tumor resectability should be confirmed according to the tumoral response The requirement of a right or left pneumonectomy should not constitute an absolute contraindication to offer neoadjuvant treatment The intrinsic characteristics of the patient and the experience of the treating center/group should be taken into account when deciding on the type of oncologic treatment to offer The administration of 3 cycles of chemotherapy plus immunotherapy with neoadjuvant intent should be considered adequate Concomitant chemo-radiation therapy with neoadjuvant intent should only be used in cases of upper sulcus tumors To evaluate respiratory function as part of the preoperative workup, FEV 1 and DLCO should always be performed at diagnosis and reevaluated after neoadjuvant treatment No consensus was reached on the benefit of offering neoadjuvant chemotherapy plus immunotherapy to patients in whom a therapeutic target including EGFR mutation or ALK translocation has been identified. In this context, patients should be evaluated by the multidisciplinary thoracic committee to determine the best approach according to the characteristics of each case Indications for neoadjuvant treatment The AJCC 8th edition TNM staging criteria for considering that the patient has potentially resectable disease and could benefit from neoadjuvant treatment include: Primary tumor 1–5 cm, T1, T2a and T2b, with N2 single station or multiple station involvement (stage IIIA) Primary tumor > 5–7 cm, T3, with N1 lymph node involvement (stage IIIA) Primary tumor > 7 cm, T4, with N0 or N1 lymph node involvement (stage IIIA) Primary tumor > 5–7 cm, T3, with N2 single station or multi station lymph node involvement (stage IIIB) Cases of primary tumor T4, with N2 lymph node involvement (stage IIIB) are underrepresented in clinical trials, so it is considered reasonable to evaluate individually and define management according to the clinical characteristics of the patient and the experience of the surgical group Patients with any T and N3 lymph node involvement (stage IIIB and IIIC) are not considered to benefit from treatment with neoadjuvant intent and should receive treatment with concomitant chemo-radiotherapy Evaluation of response to neoadjuvant therapy Radiological evaluation The images that should be performed after completion of neoadjuvant treatment are chest CT with extension to contrasted upper abdomen PET-CT to evaluate distant disease MRI should be considered in case of suspicion in CT or PET-CT of infiltration of structures contiguous to the tumor Additional imaging should be performed depending on de novo symptoms and/or clinical evidence of tumoral progression. In this case histological confirmation should be performed whenever technically possible Mediastinal restaging Mediastinal restaging should be performed after neoadjuvant treatment to guide surgical treatment only if there is doubt about tumoral response on imaging Tumoral response Resectability criteria should be considered after neoadjuvant treatment are: Initial N2 single or multiple nodal involvement with complete response on imaging Technically resectable single or multiple N2 nodal involvement with stable disease or partial response on imaging If the patient shows tumor progression during induction treatment, it is recommended that surgical treatment be withheld |
Post-surgical evaluation of patients with locally advanced NSCLC treated with neoadjuvant chemo-immunotherapy
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The surgical team providing information to the pathology laboratory regarding whether the patient received neoadjuvant therapy and the type of therapy, whether more than one tumor is present in the specimen, the correct labeling of the specimen with the resected lobe(s), and the presence of involvement of other structures such as the pericardium, diaphragm, or chest wall.
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The effect of the treatment on the primary tumor should be reported, specifying the percentage of viable tumor, tumor necrosis, stroma, and degree of inflammation.
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The effect of the treatment on the lymph nodes should also be described, including the total number of lymph node stations and nodes examined, the presence and extent of lymph node tumor involvement, and the presence of extracapsular involvement.
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Post-surgical evaluation of patients with locally advanced NSCLC treated with neoadjuvant chemotherapy and immunotherapy The cases should always be reviewed after surgery, in the multidisciplinary committee with anatomy pathologic report to define the need to administer adjuvant treatment (systemic or radiotherapy) or to initiate observation/follow-up The anatomy pathologic report should follow the recommendations of the IASCL guidelines for evaluation of response to neoadjuvant treatment and includes information about percentage of residual tumor and determination of pathologic response in primary tumor, number of resected nodes, lymph node involvement, the characteristics of the resection margins and the staging pyTNM Follow-up by medical oncology should always be indicated In case the patient presents EGFR mutation, adjuvant treatment with osimertinib should be offered It is reasonable to administer adjuvant treatment with radiotherapy in case of R1 resection In case of confirmed N2 nodal involvement, it is reasonable to administer adjuvant radiotherapy treatment only in selected cases including extracapsular nodal disease in the affected N2 station and R1 and R2 nodal resection In case the patient presents with unresectable neoplasia, definitive treatment with chemo-radiotherapy followed by durvalumab should be considered for PDL 1 positive patients who do not progress during treatment with chemo-radiotherapy In case the patient presents tumoral progression during neoadjuvant treatment, surgical treatment should be discarded and systemic treatment with focus on metastatic disease should be offer according to the clinical and pathological/biomarkers characteristics of the patient disease |
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Follow-up of patients with locally advanced NSCLC treated with neoadjuvant chemotherapy and immunotherapy Counseling and pharmacological measures for smoking cessation should be continued It is reasonable to perform blood tests and chest CT scan with contrast and medical visit every 6 months for 2 years then blood tests and a low-dose chest CT scan every year for 3 years followed by annual low-dose CT scan according to the characteristics and risk of each patient In case of suspicious radiological abnormalities, imaging control should be performed more frequently, and biopsy should be taken in cases suggestive of recurrence PET-CT should not be routinely performed for periodic follow-up, it should be indicated only in case of suspicious findings in conventional images Brain MRI or brain CT with intravenous contrast should not be routinely performed annually in the absence of neurological symptoms |