Role of Immuno- and Targeted therapy in Lung Cancer Resections

Traditionally the mainstay of lung cancer management comprised of surgery, chemotherapy and radiotherapy. The primary goal of surgery is to achieve an R0 resection whereby the lung cancer is removed with clear margins and all the appropriate lymph nodes stations are dissected for accurate pathological staging whilst preserving as much lung tissue as possible. However, despite R0 resections, 5 year recurrence can be up to 70% in stage 3 NSCLC. Increasingly, especially over the last decade, targeted therapy and immunotherapy has emerged to complement the above modalities.

Immunotherapy in addition to surgical resection in both adjuvant and neoadjuvant settings has been shown to be more effective in achieving complete pathological response and disease free survival as compared to chemotherapy alone. This is done without compromising resection rates and feasibility of minimally invasive procedures.

Adjuvant 3rd generation TKI post surgery in early stage NSCLC with common EGFR mutations demonstrated greatly improved overall survival compared to chemotherapy alone in the landmark ADAURA study. Although the use of neoadjuvant TKI is not formally endorsed in guidelines, their superior Objective Response Rate (ORR) makes it a viable alternative to neoadjuvant chemotherapy in down staging and down sizing more advanced NSCLC.

With more effective systemic therapies coming online in the near future, even stage 4 patients with oligometastasis or even oligoprogression might be deem to be resectable. There are also upcoming technologies that allow resection/ablation to be carried out with minimal morbidity