I’ll finish our session by going to both of you, starting with Dr Singh. Maybe you could say where you think the next big advances will be made, whether they’re diagnostic or therapeutic, in early-stage lung cancer.

There’s a lot of excitement in the pulmonary world about mixing diagnostic and therapeutic at the same time. For example, could that first patient who we discussed have a localized therapy delivered at the time of the diagnostic procedure, or make things super easy for the surgeon to go back? There’s a lot of interest in marking the area for a minimally invasive surgery, especially for stage I and early cancer.

As I said, there’s the aspect of following diseases chronically and figuring out surveillance regularly. What does pulmonary survivorship look like from the multidisciplinary perspective? We need to start thinking through how to survey. If something does rear its head later, do we treat it differently in future paradigms? How will that look? Would it be minimally invasive up front? Would it be longer term and we keep things in our hip pocket as the technology advances? Those are things [to think about].

From a population perspective, we have to assume that the majority of the country is not treated in major cancer centers. The majority of the country is treated in their community. When you think about it like that, leaning on other people [is important]. Let’s figure out ways by which individuals can get real-time expert advice that works and can provide some degree of team-based care in a safe, nurturing, and encouraging setting. I’m saying that because there are a lot of common principles of leadership, of convenience. How do you use data and other communication channels to optimize patient care? [How do you] minimize biases and provide meaningful, real-time decision-making? [We need to] equip that in the space no matter where a patient is, whether it’s the emergency department, the hospital setting, an urgent care facility, or in an office somewhere remote from a large team that’s fully equipped. How do those teams reach out and create clear networks, guidelines, and pathways? That’s an interesting innovation: how do we deliver high-quality care to remote sites in real time?

I love that. Technology and our ability to do an education session like this, where we can communicate with colleagues across the country, shows us that we can do that. David, what are your closing thoughts on the next big thing? You mentioned 1: the VALOR study. What do you think is going to be the next big step forward in early stage care?

There are several interesting things. I’m looking at combination immunotherapy because, as great as it is, the vast majority of patients don’t benefit. It would be nice to convert them to immunologically active tumors. Second, we’re enthusiastic about these basket trials, where we can take patients and assess them in an adjuvant fashion and fit them into trials for all of these—you mentioned 

rare mutations. [They could] potentially benefit from adjuvant therapy, but because of the minimum number of patients, any one site is not going to be able to run these trials. That’s a great new paradigm: to learn a lot about these potential novel therapies in a handful of patients who have the correct target.

That’s great. It speaks to what Dr Singh was talking about. We’re a global community, and collaboration is going to help us get answers sooner. I want to thank everybody for attending. This was a lightning round through a couple of real-world cases in early-stage lung cancer. It’s fun for me because when we started, stage IV care was rightly what we focused a lot of our research efforts on. It’s great to see that we’re talking about advances in early-stage cancer, hopefully leading to even more cures for patients. Thanks for taking the time to attend this.

Videos

Looking to the future, a panel of experts offer closing remarks on promising developments and unmet needs in the treatment of NSCLC.

Unmet Needs and Future Perspectives in the NSCLC Treatment Landscape

We’re eagerly awaiting the published and presented results of AEGEAN. There’s a press release that says AEGEAN—up-front chemotherapy plus durvalumab with consolidated durvalumab after, randomized to placebo—met the primary end point of at least 20% pathCR [pathologic complete response]. I don’t have any more information. But that’s a different regimen because it was immunotherapy up front but immunotherapy after as well. We hope we’ll be hearing about that.

Our friends in the breast cancer world have been dealing with this issue with triple-negative breast cancer. Historically they give preoperative aggressive chemotherapy up front, take them to surgery, and then flip it. Let’s say they give a platinum-taxane up front, go to surgery, and [the patient] still has significant cancer…. They’ll give adjuvant capecitabine, for example. I find myself doing more neoadjuvant therapy, but I’m not sure if I should give more. Three cycles is probably enough, but when you have somebody who still has cancer at the time of surgery, you feel like maybe you needed that fourth cycle. It’s silly to think that, but I do.

The other thing is that this woman’s case is tough because she had more cancer than we thought. We worked her up. Our pulmonologists are so good. We do extensive mediastinal evaluation, and she didn’t have any mediastinal disease preoperatively. Then we treat her. We take her to surgery, and they aborted surgery because she had extensive mediastinal disease. This raises some questions, so [afterward,] I gave her chemotherapy, radiotherapy, and I/O [immuno-oncology]. She got the kitchen sink but a different chemotherapy regimen, obviously. I don’t know if that’s the right thing to do.

That’s a great case, David. It’s obviously a real-world case, but those are the tough questions that we discuss at our tumor board. No matter where you practice, it’s ideal to have friends you can lean on—colleagues like pathologists, pulmonologists, radiation, surgical oncology, and even other medical oncology colleagues. I always learn something when I’m at a conference. You might think you know it all, but you don’t. You’ll always learn something from another set of eyes looking at something. Even the radiologist going through it at the conference teaches you something that you didn’t see on your own.

Experts discuss the role of neoadjuvant therapy and other emerging therapies in the treatment of early-stage NSCLC.

Neoadjuvant Therapy and Other Emerging Therapies in Early Stage NSCLC

Jaspal, is there anything you want to add?

This is a tough one. It’s a great case. The other part of it is what you said very nicely: you’re an oncologist first and a surgeon second. I’m a pulmonologist first and an oncologist second. With this perspective, this is chronic disease management at this point. I started thinking through his lung function, which is marginal. Now comes the point that I start predicting what his postoperative lung function will look like at best, knowing that you can’t predict that exactly. I’m also thinking of the physiology and quality of life, and how that will impact him depends partly on that.

If you can, think of what this might look like for him surgically. He’ll be treated from a cancer perspective, but it will leave him as a pulmonary cripple or severely debilitated. We’ve got to start thinking about quality-of-life vectors. That’s where it gets tricky. That’s where it gets exciting, however. If you’re on the fence of using chemoradiation or neoadjuvant therapy, if you want to wait and see, this is where our heads come together and we start thinking that through.

We don’t put a lot of emphasis on the patient decision in the multidisciplinary tumor board. We don’t have patients [participate]. This is where I’d probably think there are 2 or 3 options out there. Let’s think it through, take it back to the patient, and say what we think will be your best chance of surviving with the best chance of treatment of cancer. But let’s know that the risk of potential low quality-of-life issues might come into play, not to mention surgical complications. We might say, “Let’s try this for now.”

The important part is [knowing] that what we decide today may not be what we decide 6 months or a year from now. Start thinking about this as a maze of choices, as we move from chronic disease management. If you can go either way, as a pulmonologist, I’d go to the patient and say, “These are your 2 options. Let’s compartmentalize this a little and think this through collectively.”

I brought up the PACIFIC regimen because that N2 node we saw on PET [positron emission tomography] was negative by EBUS [endobronchial ultrasound] in a patient without the greatest function. Is this a reasonable [patient] to give definitive, nonoperative therapy? We ended up putting him on a CheckMate 816 regimen.

Cisplatin/pembrolizumab/nivolumab is [the regimen] where we used mediastinoscopy [MED] to help us to see—because this is a central tumor—if we thought those nodes were positive. Because they hadn’t had a MED and they did not get radiation, we did a MED. Then I VATS [video-assisted thoracic surgery] explored this patient…and we were able to resect it.

The patient was not a pathCR [pathologic complete response]. They had a major pathologic response—I didn’t show the slides—but they still were level 11 microscopically positive, although the tumor was quite a bit smaller. [The patient] did well. We’ve got somebody who had a short course of up-front chemoimmunotherapy, but now still has persistent disease. What are you going to think about?

I have a woman like this. These are the nightmares of the CheckMate 816 dilemma, because they responded but still have disease. Sometimes I’ve had the opposite occur: I’ve given them 3 cycles, but there’s more disease than we thought. By the letter of the law, you wouldn’t give more systemic chemotherapy. You can test for EGFR; that’s fair. I don’t think there’s a role for radiation therapy. That would be it: EGFR testing. If they don’t have it, you’d [monitor].

But what would I do? This sounds silly because you shouldn’t work based on what you think’s going to happen, but I think other trials are going to emerge shortly that are going to show us the value of neoadjuvant and adjuvant I/O [immuno-oncology]. The IMpower010 study led to the FDA approval of atezolizumab after chemotherapy in patients with stage II and III cancer with at least 1% PD-L1 expression for a year. To make myself feel better, I might do PD-L1 testing in this patient. If it’s 1% or higher, then I’d consider giving this patient a year of adjuvant I/O—mixing trials together. I want to emphasize that the right answer is to test for EGFR. That should be the only intervention you’d give if they’re positive. The real-world answer is that I’d probably give a little more. For me, that would probably be I/O.

Jaspal Singh, MD, MHS, shares insights on treatment strategies for patients with stage II-IIIA NSCLC.

Treatment Approach for Patients With Stage II-IIIA NSCLC

Let’s move forward…David, I think you had a case you wanted to take us through.

I wanted to [show] a patient where it’s really unclear on which side of the fence this patient would sit. I think we’re seeing more of these locally advanced patients. This is someone I just saw recently who is a former smoker, significant history, not great pulmonary functions, but OK, and pretty reasonable performance status, who presented with this large mass of 5 cm to 6 cm on the right side.

These are more images. First of all, the upper panel shows that it’s near the upper lobe bronchus where the PET [positron emission tomography] had a questionable N2 node. Then there’s the lesion that you can see.

The patient had a negative head MRI [magnetic resonance imaging], and the PET was otherwise negative. They underwent an EBUS-FNA [endobronchial ultrasound-guided fine-needle aspiration] with negative mediastinal nodes, but a positive 11R(+) or higher node. The bronchoscopy by the interventional pulmonary person showed tumor out in the segments of the upper lobe, which they biopsied as adenocarcinoma, and they called it T2-3 N1.

There are a lot of treatment options here. First I’ll probably ask each of my partners here, could you push this as a nonsurgical route? Which one could do. Could you push it to a surgical and adjuvant route? That’s certainly not unreasonable. Or would you push it toward the more exciting neoadjuvant approaches [such as] the CheckMate 816 type pathway? David, what do you think?

It’s a great case because you highlight the excitement. Certainly the management of stage III cancer has generally shifted more toward unresectable care with chemotherapy-RT [radiotherapy] followed by immunotherapy for true stage III cancer that we would say is probably not ideally resectable, [it is] multistation or bulky. This case is a bit different because it’s N1 disease, not N2 disease. I would think if a patient was an operable candidate, you’d want to offer them surgery.

But let’s pretend for the moment that she had N2 disease, the PET maybe suggests that. The question is, do you just say that surgery is off the table with N2 disease, or do we say surgery’s reasonable because it’s single station and low volume? And now I may be able to downstage her, so to speak, with a neoadjuvant approach, specifically CheckMate 816.

[That was] a randomized trial that Patrick Forde, [MBBCh,] from Johns Hopkin led where patients got oddly 3 cycles of platinum doublet chemotherapy with the PD-1 inhibitor nivolumab, or chemotherapy alone. The goal of the study was to look at pathologic CR [complete response] rate…. The advantage was clearly in favor of nivolumab. It was [about] a 25% pathologic CR rate vs 2% with chemotherapy alone. Surgical outcomes did not appear to be affected, maybe even less invasive surgery was done. So could you take somebody say who was marginally resectable before and make them more resectable because of this deep response rate and change the playing field? That seems to be the question right now, and I don’t have a perfect answer. I guess I’m trying to take everybody from neoadjuvant therapy who we think is a good candidate for it, but if we don’t think it’s likely that surgery is ever in the cards, then I probably would say let’s just move ahead and give definitive chemoradiation.

David H. Harpole Jr, MD, presents a case of a former smoker diagnosed with NSCLC, and David Spigel, MD, offers his initial impressions.

Patient Profile 2: Former Smoker Diagnosed With NSCLC

Jaspal, one thing that comes up sometimes is where I see a patient with stage I cancer, and somebody—maybe the internist—has said to me, “She’s not a surgical candidate. We want her to see a medical oncologist.” Who makes the call on whether a patient is a surgical candidate?

I think you’ve uncovered one of the major issues right now in thoracic oncology. The idea of what biases go into that decision, how important it is to think about the education of all people that person touches, and not just touches, but also with social media proliferation, a lot of our patients now have done an internet search on lung cancer. They immediately, despite having a curative situation, potentially, get very upset. They start thinking a lot of different things and ask a lot of questions.

I think that’s our job. This webinar is one example of trying to get the message out in public that, timeout, let’s get the information, let’s think through this space more methodically. Let’s not rule out a surgical candidacy based on what we know. Just like medical oncology has become much more sophisticated, the surgeons have done a tremendous job in their innovations and all the advances in surgical treatments. Now they’re getting outstanding outcomes [versus] traditionally like when I trained back in the day at Duke [University]. [With] people who are being operated on now, it’s pretty impressive.

We also see it in the pulmonary community, “People are too high risk for a bronchoscopy.” We treat oxygen-dependent [patients], people who are very frail, very debilitated, and we have incredible outcomes despite all the comorbidities. The medical science has advanced. It has done it for all phases of the thoracic oncology world. I would say to err on the side of assuming your patient wants the best chance of survival.

David, we’ll finish this case with your thoughts about that very question. Obviously, you’re a little biased. What would it take for you not to operate on a patient? I presume it’s the obvious: cardiac and pulmonary status.

I’ll throw this out there; I’m a co-PI [principal investigator] of the VALOR trial with Drew Moghanaki, [MD, MPH,] from [the University of California Los Angeles] who’s a radiation therapist. We’re looking at normal-risk patients being randomized to lobectomy or SBRT [stereotactic body radiotherapy]. I think that this may be changing. I always remind people that I am a modality person, but I am an oncologist first and a surgeon second, so I want my patient to get the best therapy possible, which may or may not be surgery. It’s pretty rare for us to have people who aren’t surgical candidates for something. But the point of putting our heads together as a multidisciplinary team is deciding, is that the best treatment for this individual patient? I think that’s the key question here.

What is the future for stage I cancers besides surgery alone? This is a subject of ongoing investigation. It has not been the most attractive area initially for our pharmaceutical and biotechnology partners, but I think it’s changing. Particularly with, as we mentioned, the TKIs [tyrosine kinase inhibitors], but also immunotherapy finding its way into stage II and III adjuvant care and neoadjuvant care, I think we can imagine a future where there might be some high-risk stage I cancers where hopefully in randomized trials an intervention shows benefit in terms of OS [overall survival]. That may be immunotherapy, but who knows? We have to wait on those data to come out. You guys know well that stage I has a bit of variation in terms of risk for recurrence, so we shouldn’t just treat it as 1 entity. There can be very low risk and very high risk in stage I.

An expert panel shares perspectives on how to choose the appropriate patients with non-small cell lung cancer for lung resection.

Choosing Appropriate Patients for Surgical Resection in NSCLC

Let me swing this to you guys. Today, I got called by a colleague who had what they thought was early-stage cancer. I hadn’t seen the patient yet, he was asking me if I could help. When they got to surgery, he said [there was] a tiny amount, I guess a microscopic amount of disease, and an N2 node, and that’s it. Technically it was a stage III cancer at the time of surgery. He was asking what more we should do. I told him I didn’t think there was an indication for radiation, and we talked about the benefits of adjuvant chemotherapy. I said, “Are you going to ask me about EGFR?” He goes, “I’ve got one better for you. The patient came back with a 

This comes up [sometimes]. In stage IV cancer, we know very well that there are 7 other targets besides EGFR that we have therapies for. It’s important for this session that we’re doing with potentially a global audience here that there’s no indication for any adjuvant TKI [tyrosine kinase inhibitor] use outside of EGFR at this point. We’re waiting for additional information from ongoing cooperative group adjuvant studies to know what to do for other alterations, like 

I’ll throw it back to you guys. Dr Singh, in this case, the patient’s EGFR status was unknown. What are you doing when I call you up and say we didn’t get enough tissue, or for whatever reason EGFR status wasn’t tested? How do you usually respond to that or address that?

If it makes a difference to your treatment options, obviously I don’t offer that treatment myself in my discipline, but if that was something you needed, we’re here to serve. That’s what the pulmonologists do basically. We say, “We can get this to you.” If we can get enough information to you safely and expediently, then I think we will likely try to help you as quickly as possible.

David, do you know if your team runs it on the biopsy that Dr Singh [would do]? Or do you wait and just do it on the specimen you take out?

It depends on what we’re thinking about. For an isolated lesion like this, we probably would only do it on the latter. For anything more than this, as Dr Singh pointed out, where we’re looking at other levels, invasive stages and stuff, we very likely may run the EGFR. We often do that as a single mutation panel just for that 1 test right now, and we’re doing it up front from a biopsy, as opposed to some sort of next-generation sequencing group. But I think this is changing and evolving very rapidly.

A panel of distinguished experts discuss how detection of actionable mutations affect their treatment choices in non-small cell lung cancer.

Therapies Targeting Specific Molecular Alterations in NSCLC

Let’s talk about what we’re dealing with here. We have stage I adenocarcinoma. The surgical outcomes look good, it was a lobectomy, the margins [and nodes] were negative, and there were no other high-risk features. We presume the patient had a great recovery and there were no other suspicious findings. As we all know, in real life, the PET [positron emission tomography]–CT scan isn’t exactly perfect. There are always some other nodules or something else you’re trying to figure out if it is connected or not. So the patient comes in to see [one of us] and is saying, “What else do I need to do?” Dr Singh, maybe you don’t have adjuvant discussions, and you leave that to your radiation medical oncology colleagues, but it is your sense that this patient is done, or [do they] need other therapy?

There’s some variability here. Obviously, there are some data to suggest they might benefit from additional therapy, but for now, I think we’re still trying to figure this out. I think it’s an individualized discussion at this point. The fortunate part, which you mentioned earlier, [is that] the bronchoscopy now can get you enough tissue for molecular testing. We try to give that option. Should that patient opt to proceed with something systemic, I think we’ll have that option for them. I think the word is still out though. There are some data to suggest that this patient may be done, but there are some patients, high-risk patients for example, for whom the medical oncology community may say, “This patient really wants to try something additional.” I think we can get into that, and there’s a suggestion of some data to support that. But again, it’s an individual decision, and I don’t think there’s a universal solution quite yet.

I think that’s fair. In some parts of the world, in Southeast Asian countries, there are some adjuvant recommendations for a 5-FU [5-fluorouracil]–based regimen in stage I cancer. In the United States, that has not really been adopted. In general, for smaller stage I cancers, we generally don’t recommend chemotherapy, although we have that conversation. The latest question that comes up is, is there a role for immune therapy or targeted therapy? Let’s start with EGFR because these are the more relevant things to discuss. David, to swing it back to you, are you getting 

 mutation testing done on every patient you operate on regardless of anything else?

This particular case is an under-3-cm tumor with no high-risk features. I think most of us would not recommend adjuvant therapy, except on [a clinical] trial, for this patient. We are getting pretty much reflex testing of all of our resected patients. But if [a patient] is at a smaller center, for less than 3-cm lesions, it’s probably not unreasonable to hold back on that. I think all the information we can gain is important. God forbid, if this patient recurs, it would be nice to have had that information beforehand to help you, David, if you’re looking at a recurrence situation and what to do for next therapy.

Yes, I think that’s well said. I’ll reference for our viewers [that] what Dr Harpole is alluding to is the ADAURA study. This is a trial that was trying to define the role of adjuvant EGFR TKI [tyrosine kinase inhibitor] therapy, osimertinib, in patients with 

mutations. To run through things quickly, this study took patients with stage I through stage III disease, but everybody had an 

 mutation. Patients would get chemotherapy or not, according to their doctor’s preference. It was a global study, and so there were a lot of patients with stage III cancer who didn’t get adjuvant chemotherapy. Everybody was randomized to osimertinib or not. The trial had a disease-free survival [DFS] end point, and you stayed on osimertinib for 3 years.

The trial demonstrated a DFS advantage in favor of osimertinib, and osimertinib was FDA approved in the United States for adjuvant use, but there are a couple of caveats. No. 1 is we’re waiting on overall survival data. No. 2, remember that chemotherapy was optional. The FDA approval was really for stage II and stage IIIA disease. If you go to the 

 paper and you go to the appendix, there’s a nice graph of the different stages and the DFS for each of those stages [of cancer], even though for the overall intent-to-treat [population], the primary end point was in stage II and stage III. There is an advantage that is demonstrated for stage I cancers for osimertinib vs not, but not powered enough to be in the intent to treat—it was not a primary end point, so it was a secondary end point mixed in with all the other stage II and stage III patients.

So, what to do? For patients in front of you in the office, the textbook technical answer is there’s no indication for adjuvant osimertinib in stage I cancer. However, I still have the conversation with the patient. I let them know what the trial showed and didn’t show, and what the FDA approved. I’ve had some patients say they want to do it. I’ve had a couple pursue it, and of course, I helped them pursue that, and we were able to get it. It’s outside the label, it’s not indicated, but if you have a conversation with the patient, [it may be] still what they want to do.

David Spigel, MD, and David H. Harpole Jr, MD, describe when adjuvant therapy is recommended in early stage NSCLC and discuss data from recent clinical trials of adjuvant therapy.

Adjuvant Therapy in Early Stage NSCLC

Recently I saw a woman with—very much like this case—a stage IA cancer that was resected. It was [performed by a] surgeon in town I don’t work with that much. I noticed the patient had a wedge resection. The patient came to see me and said, “What else do I need to do?” As we’ll talk about in that case, there was no indication for PD-L1, EGFR, or chemotherapy. But I couldn’t shake it, part of me was thinking, “You didn’t really have the ideal surgery.” What are your thoughts about, maybe not that case, but am I wrong [that] we’re still aiming for lobectomies? I guess the better way to ask this question is, when is a wedge good enough?

There have been 2 really important studies that came out in the last 12 months. One was the JCOG0802 study, which randomized 1100 patients to lobectomy or segmentectomy. Those were 2-cm or smaller adenocarcinomas. That revealed a slight improvement, interestingly, in overall survival for the segmentectomy, but a higher local recurrence rate. Then [there was] the CALGB 140503/Alliance trial, [Nasser] Altorki’s, [MD,] trial, which was segmentectomy or wedge vs lobectomy on around 900 patients, which showed equivalency.

I always bring out the key point that in the Altorki trial, which we put a number of patients on, the patient had to have a diagnosis of cancer, but more importantly had to have all nodal stations sampled in the operating room and found to be negative prior to randomization, which was not the case for the Japanese trial, where they had some node-positive patients. It makes it confusing, but right now, we don’t ever believe a wedge should be primary therapy in a good-risk patient. If one is going to entertain that idea, they certainly need to do a full nodal staging with that to get the answer.

I apologize, I’ve not always equated wedge with segmentectomy. I thought segmentectomy was even a little more, am I right?

The segmentectomy is what we and thoracic surgical oncologists prefer because when you do the segment, you dissect down into the segmental bronchi. So by definition you get the 11, 12, and 13 nodes, but more importantly, it’s an anatomic resection where you take the artery, vein, and bronchus together, whereas a wedge is just basically taking a chunk out. So we really do favor segments.

Yes. It’s frustrating when you’re seeing somebody with such good outcomes. You don’t want to disparage your colleagues in the community, but it struck me that that wasn’t the appropriate surgery for that patient.

There’s that very depressing SEER [Surveillance, Epidemiology, and End Results] data set, which looked at patients who had either lobectomy or wedge, and then just stratified by number of nodes taken, and there was a dramatic difference in 5-year survival. It’s clearly stage migration. In other words, the ones who were really staged with nodes did much better than those who weren’t. When you have someone with a wedge with no nodes, you really don’t know what stage they are, and it makes it more difficult for you to figure out therapy.

Yes. Fortunately, she had all the nodes sampled that we needed.

A panel of experts in the treatment of NSCLC discusses how they manage patients with stage IB disease.

Treatment Approach for Patients With Stage IB Disease

David, I’m curious. When I started almost 20 years ago out of training, I remember the surgeons I worked with and they were great. Their advice was, if it’s a solitary lesion, just take it out, don’t even bother biopsying it. Of course, back then we were just learning how to do PET [positron emission tomography] scans. [Discuss] your thoughts on how a patient who comes to you at Duke [University Medical Center] approaches with a solitary lesion. What are you doing? Are you doing a PET scan? If I’m not mistaken, I think you do your own scopes, but could you expand on your approach to the workup of a solitary lesion?

It has certainly evolved, and frankly, most rapidly over the last 2 to 4 years. As this wave is moving across the country and things are changing, I will tell you, we were a universal mediastinoscopy center for everyone. I used to do literally 300 or 400 a year, and now I do like 15…. I think the EVIS EXERA III platform that we use, and interventional pulmonary uses, has supplanted that. I will say that with the robotic platforms now, I think that has been our primary [procedure] as well. The reason being is that historically, [with] a 2-cm lesion like this that’s suspicious, we would’ve just taken it out without a diagnosis. We can go more into about the size and what we find, but certainly lesions greater than 3 cm where there are some other options now, we have been getting not only cytology but histology and molecular information on them, and we’re going to obviously discuss that more.

This [case] is pretty much a straightforward T1 lesion that I would say probably half of the thoracic surgeons now would take out without a diagnosis. We tend to get a diagnosis now more than we used to, and I think it has killed 2 birds with 1 stone because with EVIS EXERA III and our navigational [bronchoscopy], we can get a tissue diagnosis of the lesion as well as the nodal stations at the same time. This is truly a team [effort], and I think our interventional pulmonary team has become even more important to that.

David H. Harpole Jr, MD, a thoracic surgeon, details his workup approach and discussed molecular testing for patients who present with NSCLC.

Workup and Molecular Testing for a Patient with NSCLC

We’ll start with the first case. Let me walk you both through this. This is a 57-year-old woman who’s a nonsmoker, which is probably not [the majority of the patients] for the 3 of us who operate in a tobacco region in the Carolinas and Tennessee. This patient was found to have ground-glass opacity in the right upper lobe in 2016. Five years later, this imaging showed presence of a dense, nearly 3-cm lesion, so not just a wispy abnormality, but a defined lesion in the right upper lobe. Bronchoscopy revealed adenocarcinoma. Further imaging included a PET [positron emission tomography]–CT [computed tomography] scan, which did not show any evidence of distant disease. This patient underwent a right upper lobectomy, which again revealed adenocarcinoma with negative margins, but also negative nodal involvement. There were no other signs of maybe a more aggressive cancer, no LVI, lymphovascular invasion, or visceral pleural involvement. The EGFR status was unknown.

Dr Singh, I’ll start with you on some basic things to talk about. When I meet patients perhaps not from my system, and I see they’ve had a bronchoscopy, I always wonder whether it’s like what happens at our center, where we do navigational bronchoscopy and are able to get really good samples of tumors? Talk a bit about your approach to the different technologies and working [patients] up. At least at my center, we’ve shifted away from our surgeons in terms of [them] getting us tissue and a diagnosis. We’re looking for our pulmonologist to do that. But Dr Singh, talk about how you approach that initial evaluation.

Thanks, Dr Spigel, for teeing me up with that good question. There is a lot of variability obviously. This is a huge issue in our country right now to figure out, the variability is almost astronomical. This can start in many different ways, depending on the community that you’re in. I’m part of a large health system. I used to say that my job was actually medical director of pulmonary oncology quality. We struggle with this, because I work at a center that has a lot of bells and whistles. I have navigational [bronchoscopy], but I also have robotic-assisted navigational bronchoscopy. It’s the frontier now for the entire lung. Minimally invasive biopsy is potentially at our doorstep. It’s great, but it’s not the reality in many centers. People who might be in the audience, for example, may not have access to these things.

Through robotic bronchoscopy—I did a few today, for example—we can do all kinds of biopsies for cytology alone, but also for these types of ground-glass opacities. This [patient’s lesion is] dense, but you can use a variety of different tissue tools to acquire that lesion, anything from needles to forceps, now even with a cryoprobe where you get larger pieces of tissue. So tissue volume, histologic architecture, immunostaining, and molecular testing for minimally invasive biopsies is well within reach through bronchoscopy in many centers, and it’s expanding.

That being said, many places don’t have that. So then you have to start thinking, what can I do to accomplish my goals? This situation is potentially a stage I disease. We have to figure out, do we need to do a minimally invasive biopsy, or do we trust the other aspects of PET-CT? That’s going to vary from place to place. This is where we have a bit of variability, and we’re still learning in the space. It’s also institutional preference or surgical preference, if a surgeon wants a biopsy vs they don’t need a biopsy. If all roads lead to resection, do you really need to have a biopsy? These are things we’re still struggling with. Just because we can, should we?

Now, this lesion is borderline, up to the point where in our center and with the guidelines, at 3 cm in 1 dimension, we probably should do invasive staging of the mediastinal preoperatively. That’s where in bronchoscopy, that 3-cm mark from a system perspective is our hard stop. You might say it’s our quality metric. At that point, 3 cm is where we educate our oncology community to say, we need to at least consider invasive mediastinal nodal staging if we can, if it can’t be done surgically. For patients who are nonsurgical candidates, hilar node staging [should be done] as well, to make sure that our radiation oncology colleagues can obtain the information they need to proceed. And with bronchoscopy, nodal staging is extremely low risk in skilled hands, so that’s a nice dimension to have. The further you get out with the lesion, the harder they are, but we’re getting to very tough areas where we successfully biopsied areas that traditionally had not been accessible to the pulmonology community.

Thanks. [Those are] so many great points.

David Spigel, MD, presents a patient case of a 57-year-old woman with NSCLC, and Jaspal Singh, MD, MHS, discusses his approach to initial evaluation.

Patient Profile 1: A 57-Year-Old Woman Diagnosed With NSCLC

Hello, I’m Dr David Spigel, a thoracic medical oncologist and the chief scientific officer at Sarah Cannon Research Institute in Nashville, Tennessee. It is my privilege to be joined by 2 great colleagues to discuss recent advances in the management of early stage non–small cell lung cancer. There’s been a lot going on, certainly a lot of breakthroughs in the last year that involve not just medical oncology obviously, but surgical and radiation oncology as well.

We have some cases we’re going to go through over the next 45 minutes or so that I hope highlight some of these recent advances, but maybe even more importantly, some of the challenges we still face as these new breakthroughs come into play and how we incorporate this into standards of care, and of course, what the next big questions will be. Before we dive into the cases, I’ll start with some introductions of my colleagues and let them introduce themselves. We’ll start with Dr Singh.

Hi. Thank you so much. I’m Dr Jaspal Singh. I’m a pulmonologist in Charlotte, North Carolina, at Atrium Health and Levine Cancer Institute. I’m a clinical professor at Wake Forest School of Medicine, where I’m a pulmonologist. My job is to tee people up for the rest of the oncology team to move quickly, expeditiously, and safely with the best chances for cures.

Hi, I am Dr David Harpole. I’m a professor of surgery and pathology at Duke [University Medical Center, Durham, North Carolina] and one of the directors of our thoracic oncology program.

Great. Thanks, Dr Harpole. I’ve had the chance to do several multidisciplinary education events with Dr Harpole. I think, Dr Singh, you and I may have worked together before too, but I look forward to this conversation. I would bet our conversation over the next 40 minutes or so is not unlike what happens for the 3 of us every day. In my case, I’m on the phone or texting my interventional pulmonology colleagues and radiation and surgical oncology colleagues almost every day about patient care. I’m sure that’s the same for you when you interact with your medical oncology colleagues. I think lung cancer always has been the best example of multidisciplinary care in terms of how you incorporate new advances as they occur.

I thought it might be best if we do these cases together, not just reserve it for pulmonary or surgery, and we’ll demonstrate how each of the disciplines gets involved in care. We have a couple of cases here. [There may even be] time to discuss some other things that come up.

A panel of experts introduce themselves and explain their approaches to multidisciplinary care in treating non-small cell lung cancer.

Jaspal Singh, MD, MHS

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