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Stage IIIB Lung Adenocarcinoma With EGFR L858R Mutation
- Written by
-
Michael
J.
Grant
MD
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paola antonelli
ICI in EGFR mutant NSCLC are not recomended. If possibile I'd choose an EGFR TKI, like Osimertinib (as in adjuvant setting)
Jean-Yves Douillard
Standard of care for locally advanced unresectable NSCLC has recently changed with the addition of Durvalumab post treatment with concurrent chemoradiation. In the present case above, the patient however has an L858R EGFR mutation. In the Pacific trials, these patients were eligible but represent only 34/709 patients in total. According to the latest updated (early 2021) Forest plot, EGFR mutated patient do not be benefit from consolidation with Durvalumab on OS (HR 0.97; 0.40-2.33), and cannot be recommended The use of adjuvant Osimertinib as consolidation in the setting of Stage IIIB post chemoradiation is less documented. Trials evaluating Osimertinib post resection have shown a benefit in DFS but there is no proof of an OS benefit. The risk/benefit of consolidation has not been evaluated. Toxicity and Quality of life have to be considered in patients potentially cured after chemoradiation. Prognostic biomarkers are needed to potentially help treatment decision, in that instance circulating tumour DNA (ctDNA) could be used and if ctDNA is detected, Osimertinib could be prescribed and its efficacy measured of repeated ctDNA testing. If not, I would personally opt for an imaging surveillance or look for a clinical trial addressing the question.