After the radical surgery of lung cancer patients, should they be treated or not, and what treatments should be done? This question has been written many times before, but with the release of the new version of the guide, there are some new knowledge and ideas that have been updated, and today I will talk in detail about how to treat patients with different stages of lung cancer after surgery.
Stage 0 (carcinoma in situ)
No treatment is required after surgery, and regular follow-up is required, follow-up is performed every month of surgery, followed by CT once a year.
Phase IA
Guidelines, including microinvasive cancers, as well as IA1, IA2, and IA3 for invasive carcinomas, do not recommend postoperative adjuvant therapy. Postoperative adjuvant therapy is not recommended in some patients with stage IA, even if there are risk factors (micropammillary, solid, vascular carcinoma embolism, air cavity dissemination, etc.), indicating that the benefit is not great. If financial conditions permit, a blood MRD test may be done to guide the need for treatment.
Phase IB
Patients with EGFR mutation-positive non-small cell lung cancer in stage IB may be considered postoperatively for oshitinib, which reduces the risk of recurrence or death by 61% for 3 years.
Adjuvant chemotherapy (adenocarcinoma: pemetrexed plus platinum, squamous carcinoma: gemcitabine, yesteria, or vinorebine plus platinum, chemotherapy 4 cycles) can be performed in patients with high-risk factors (eg, low-differentiated tumors, visceral pleural invasion, vascular invasion, intra-air cavity dissemination, etc.) in patients with stage IB with EGFR mutation-negative patients.
Phase II (IIA and IIB)
Stage II patients with positive EGFR mutations, postoperative routine adjuvant chemotherapy, chemotherapy after 4 cycles of targeted therapy maintenance, the drug can choose osimitinib, gefitinib, erlotinib or exetinib, for osimertinib is generally recommended for oral 3 years, a generation of targeted drugs recommended for 2 years.
For EGFR-negative stage II lung cancer, patients are not benefited by 4 cycles of postoperative adjuvant chemotherapy (the same regimen as before), and chemotherapy beyond 4 cycles. Adjuvant chemotherapy is usually started 4 to 6 weeks postoperatively and no later than 3 months postoperatively.
Stage IIIA of radical surgery
In patients with stage III.A EGFR mutation-positive non-small cell lung cancer, the same adjuvant chemotherapy after surgery for 4 cycles, followed by sequential targeted drug maintenance, osimtinib is preferred, gefitinib, ektinib, and erlotinib are also alternatives. Osimitinib is preferred because it reduces the risk of stage III brain metastasis and death by 82%.
Stage III EGFR mutation-negative non-small cell lung cancer requires postoperative adjuvant chemotherapy to reduce the risk of recurrence and metastasis. The PD-L1 inhibitor atenizolizumab was maintained as an adjunct therapy after surgery and chemotherapy in all people with stage II-IIIA non-small cell lung cancer, and its disease-free survival (DFS) showed statistically significant improvements. Postoperative adjuvant immunotherapy will be a trend, but it is not currently recommended by guidelines. Whether to consider use, patients and families need to fully communicate with the doctor and weigh the pros and cons.
For patients with stage IIIA lung cancer, the risk of recurrence and metastasis is greater, and the follow-up and re-examination is carried out once within 2 years after the end of adjuvant chemotherapy for 3-4 months, and once the tumor markers are elevated, vigilance is required, and when there are signs of recurrent metastasis in imaging, it is timely treated according to advanced lung cancer.
About postoperative adjuvant radiotherapy
In previous guidelines, patients with lymph node N2 have been shown to have some benefit from adjuvant radiotherapy, but recent trials have shown that the benefit is not significant and that cardiotoxicity increases. Therefore, the 2021 guidelines believe that adjuvant radiotherapy is not recommended in patients from N0 to N2.
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