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🌱 來自: management of Stage IV metastatic disease

management of Stage IV metastatic disease of NSCLC

• 6-mo BSC, 10-mo plat doublet, 12-mo plat doublet + Bev (NEJM 2006;355:2542), 3-y EGFR Mt EGFR TKI, 5-y+ ALK Mt ALK TKI 5y OS: 20% if PD-L1+, 30% if PD-L1 ≥50% to checkpoint inhibitor (JCO 2019;37:2518), ↑ OS w/ early palliative care (NEJM 2010;363:733)
• Initial tx: If sensitizing EGFR/ALK, see Targeted therapy; If driver neg, pembrolizumab, atezolizumab, cemiplimab if PD-L1≥50% (RR ∼45%) (NEJM 2016;375:1823). If PD-L1 <50%, 4-6 cycles of plat doublet+checkpoint inhibitor (RR ∼50%) (NEJM 2018;378:2078; NEJM 2018;379:2040). AdenoCAs: CIS or carbo/peme ± Bev (if eligible: No-SQCLC, no hemoptysis) vs. SQCLC: Carbo/paclitaxel, nab-paclitaxel
• Other initial: Ipi/nivo in TMB ≥10 mt/mb (NEJM 2018;378:2093), atezo+carbo/taxol+ Bev in non-SQCLC, EGFR/ALK post TKI (NEJM 2018;378:2288), ipi/Nivo w/ plat doublet x2cy (Lancet Onc 2021;22:198)
• Maintenance tx: For CR/PR/SD after 4-6 cycles of plat doublet. D/c plat. Continue peme ↑ OS (PARAMOUNT, JCO 2013;31:2895), peme + Bev ↑ PFS (AVAPERL, JCO 2013;31:3004), GEM ↑ PFS (JCO 2012;30:3516)
• Subsequent therapies: Nab-paclitaxel, docetaxel, peme, GEM, vinorelbine, checkpoint inhibitors if not prior: Nivo, pembrolizumab, atezolizumab, ramucirumab + docetaxel (Lancet 2014;384:665)
• Limited met sites: (Oligomets): Consider surgery, RT, ablation
• RT to symptomatic sites: Lung, brain (SRS preferred over WBRT), bone lesions, SVC syn
• Bone Mets: Denosumab or ZA reduces SRE; symptomatic: Palliative RT
• Brain Mets: Multidisciplinary involvement of neuro-oncology/neurology, rad onc/neurosurgery; symptomatic: Start dexamethasone
• Leptomeningeal dz: Consider VP shunt if symptomatic w/ ataxia, encephalopathy, urinary incontinence; WBRT role limited (JTO 2012;7:382). If EGFR Mt (double dose) osimertinib 180 mg (JCO 2020;38:538).
• Symptomatic pleural effusion: PleurX w/ talc pleurodesis (NEJM 2018;378:1313), thoracic surgery referral for VATS pleurodesis