Sublobar resection for early-stage non-small cell lung cancer and current advances with immunotherapy in multimodality treatment of resectable non-small cell lung cancer

Introduction

Thoracic surgery is a specialty that has rapidly evolved over the last decades. The technological progress resulting in the further development of minimally invasive surgery is one of the main pillars of that evolution. The advent of video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) and the improvement of surgical staplers and energy devices changed how thoracic surgeons operate nowadays. In recent years, the extent of surgical resection for early-stage non-small cell lung cancer (NSCLC) and the role of surgery in the multimodality setting have been at the center of interest. Therefore, the role of surgery is currently redefined.

For that reason, the two significant advances in the field of thoracic surgery observed in the last few years are the establishment of the role of sublobar resection for early-stage NSCLC and the integration of surgery in multimodality treatment protocols.

Sublobar resection for early-stage NSCLC

Lobectomy was considered the standard of care for the treatment of early-stage NSCLC for decades. The randomized study by the Lung Cancer Study Group chaired by Ginsberg et al. in 1995 compared lobectomy to sublobar resection for treating peripheral cT1N0 NSCLC (measuring 3 cm or less in all dimensions) (1). In the limited resection group, there was a 75% increase in recurrence rates. It is explained by the fact that compared to individuals who received lobectomy, there was a confirmed three-fold increase in the local recurrence rate, a reported 30% rise in the overall mortality rate, and an observed 50% increase in cancer-related death rate (1). The investigators concluded that lobectomy is the gold standard in this particular setting, and this conclusion guided the surgical practice for many years. However, in the study’s design, the “lesser resection” group consisted of anatomical segmentectomies and large wedge resections, and the overall survival (OS) difference was only at the significance limit.

In 1997, Landreneau et al. compared wedge resection to lobectomy, demonstrating the latter’s superiority over non-anatomic resection (2). In the next years, many studies aimed to address that issue, but the definition of sublobar resection, which was not always the same, and the consequent heterogeneity of the assessed populations regarding the extent of resection hindered the extraction of pertinent conclusions (3-9).

A systematic review and meta-analysis published in 2020 did not find significant differences in oncological outcomes between segmentectomy and lobectomy for stage I NSCLC smaller than 2 cm. For larger tumors, lobectomy yielded superior outcomes. It has to be noted that a significant limitation of this study was the retrospective design of the studies included in the analysis (10).

Stamatis et al. studied perioperative complications and quality of life in patients with NSCLC stage IA (≤2 cm) following segmentectomy compared to lobectomy in a prospective, randomized, multicenter phase III trial. Perioperative complications and morbidity were not significantly different between the two groups, whereas patients in the segmentectomy group presented a better quality of life (11). The authors published the oncological outcomes in 2022 (DRKS00004897 trial). OS at five years was 86.52% in the lobectomy group compared to 78.21% in the segmentectomy group. Disease-free survival (DFS) was 77.29% for the lobectomy and 77.96% for the segmentectomy patients. At a median follow-up of 5 years, no differences were noted in either the locoregional or distant recurrent disease in both groups. The authors concluded that larger randomized studies needed to corroborate these early findings because the non-inferiority of segmentectomy was only demonstrated for DFS and not for OS (12).

The dogma of the superiority of lobectomy over limited resection for early-stage NSCLC was also challenged by the Japanese JCOG0802/WJOG4607L trial, a multicenter, phase 3, randomized, controlled, non-inferiority trial (13). Patients with clinical stage IA (≤2 cm; consolidation-to-tumor ratio >0.5) peripheral NSCLC were enrolled. In total, 1106 patients were randomly attributed to receive either lobectomy (n=554) or segmentectomy (n=552). OS was set as the primary endpoint. At a median follow-up of 7.3 years, the 5-year OS was 94.3% [95% confidence interval (CI): 92.1–96.0] for segmentectomy and 91.1% for lobectomy (95% CI: 88.4–93.2). Superiority and non-inferiority in OS were confirmed [hazard ratio (HR) 0.663; 95% CI: 0.474–0.927; one-sided P<0.0001 for non-inferiority; P=0.0082 for superiority]. The 5-year relapse-free survival (RFS) was 88.0% (95% CI: 85.0–90.4) for segmentectomy and 87.9% (95% CI: 84.8–90.3) for lobectomy (HR 0.998; 95% CI: 0.753–1.323; P=0.9889). Local relapse occurred in 10.5% of patients who underwent segmentectomy and in 5.4% for lobectomy (P=0.0018). In light of the OS data and despite the higher risk of local recurrence, the investigators concluded that the recommended treatment for patients with small-sized peripheral NSCLC should be segmentectomy. In the lobectomy group, other causes of death predominated; the most common of them were malignancies, particularly recurrent primary lung cancer.

A supplemental post-hoc analysis of the JCOG0802/WJOG4607L trial demonstrated that in patients with pure-solid NSCLC, segmentectomy increased OS compared to lobectomy. However, the patient’s age and gender have an impact on the segmentectomy’s survival rates. This exploratory analysis suggests that more investigation is required to identify clinically meaningful justifications for segmentectomy in NSCLC that is radiologically pure-solid (14). It has to be noted that segmentectomies involving more than two segments may not provide a clear functional advantage. The JCOG0802/WJOG4607L study did not meet the expected outcomes regarding the benefit of segmentectomies in postoperative respiratory function. Therefore, less lung parenchyma resection would not always result in improved function preservation; this could be because the remaining lobe after segmentectomy expands to an unsatisfactory degree.

Another study eagerly expected by the thoracic surgical community is the CALGB140503 trial, a phase 3 randomized trial comparing lobectomy and sublobar resection (segmentectomy or wedge resection) (15). The primary endpoint was DFS. In total, 697 patients were assigned to undergo sublobar resection (340 patients) or lobar resection (357 patients). It should be noted that intraoperative frozen section analysis of 3 lymph node stations was required to prove N0 disease. After a median follow-up of 7 years, sublobar resection was non-inferior to lobectomy for DFS (HR for disease recurrence or death, 1.01; 90% CI: 0.83 to 1.24). Furthermore, OS after sublobar resection was similar to lobectomy (HR for death, 0.95; 95% CI: 0.72 to 1.26). The 5-year DFS was 63.6% (95% CI: 57.9% to 68.8%) after sublobar resection and 64.1% (95% CI: 58.5% to 69.0%) after lobectomy. The 5-year OS was 80.3% (95% CI: 75.5% to 84.3%) after sublobar resection and 78.9% (95% CI: 74.1% to 82.9%) after lobectomy. There was no discernible difference in the two groups’ distant or locoregional recurrence rates.

Among the 340 patients assigned to sublobar resection, 201 (59.1%) underwent wedge resection, and 129 (37.9%) underwent an anatomical segmentectomy.

According to the authors, the consistency of outcomes between the two newly published trials is comforting, although there are variations in study design. These results confirm that sublobar resection, either by wedge resection or anatomical segmentectomy, is a valid therapeutic strategy for this subset of NSCLC patients with clinical T1aN0 disease. However, the differences in populations and study designs between the trials must be noted. For example, differences in OS between the study populations (5-year DFS rate in the CALGB140503 trial was only approximately 60% with either surgical procedure) highlight the influence of confounding factors like smoking history and comorbidities on reported outcomes.

The available evidence inevitably led European and Asian experts to seek consensus and publish their recommendations about segmentectomy to provide definitions, standardize the procedure, and guide surgical practice (16,17).

Integration of surgery in the multimodality therapy of resectable NSCLC

Together with technological developments, there have been remarkable advances in the pharmacological aspect of cancer therapy. New molecules are constantly added to the armamentarium of medical oncologists. Even though upfront surgery is an option when technically feasible, surgical resection can be integrated into a multidisciplinary frame and be part of multimodality treatment protocols. Societies and expert panels endorse these changes, and recommendations encompassing the newly available treatments have been published (18).

The LACE (Lung Adjuvant Cisplatin Evaluation) meta-analysis published in 2008 demonstrated an improvement in 5-year OS of approximately 5% in patients who received adjuvant chemotherapy (versus no chemotherapy) after complete resection of NSCLC (OS HR =0.89) (19). However, a high risk of recurrence in stage II–III NSCLC was demonstrated despite the use of adjuvant chemotherapy. Similarly, the NSCLC Collaborative Group meta-analysis included studies comparing neoadjuvant chemotherapy with subsequent surgery versus surgery alone (20). A benefit of approximately 5% in 5-year OS in patients who received neoadjuvant chemotherapy was observed (OS HR =0.87), which is not different from adjuvant chemotherapy.

Current changes in the treatment landscape of resectable NSCLC include the development and approval of immune checkpoint inhibitors (ICI), which can be added to treatment protocols, either in the neoadjuvant or adjuvant setting, and combined with traditional systemic therapies.

NADIM I is a single-arm phase II trial that examined the effectiveness of nivolumab in combination with chemotherapy in the neoadjuvant setting, followed by adjuvant nivolumab for a year, in operable stage IIIA (N2 or T4N0/N1 disease) NSCLC (21). An astounding 81.9% 3-year OS was recorded (22).

These results were validated in the randomized phase II NADIM II study, which demonstrated a notably improved progression-free survival (PFS) and OS in the chemotherapy plus nivolumab group compared to chemotherapy alone. This trial recruited patients with resectable stage IIIA or IIIB NSCLC who were randomized to receive neoadjuvant nivolumab plus platinum-based chemotherapy (experimental group) or chemotherapy alone (control group), followed by surgery. Patients in the experimental group who had a complete resection received adjuvant treatment with nivolumab for 6 months (23). The primary endpoint was a pathological complete response (pCR). A pCR was achieved in 37% of the patients in the experimental group and 7% in the control group (relative risk, 5.34; 95% CI: 1.34 to 21.23; P=0.02). PFS at 24 months was 67.2% in the experimental group and 40.9% in the control group (HR for disease progression, recurrence, or death, 0.47; 95% CI: 0.25 to 0.88). OS at 24 months was 85.0% in the experimental group and 63.6% in the control group (23).

As a result, these two studies established the role of ICI in the perioperative setting since immunotherapy was also administered as a neoadjuvant and adjuvant treatment. Many subsequent phase 3 trials further investigated the role of ICI and tyrosine kinase inhibitors (TKI) in resectable NSCLC. Table 1 presents an overview of these key trials.

CheckMate 816 is a phase III trial that enrolled 358 patients with stage IB to IIIA resectable NSCLC who were randomly assigned to receive neoadjuvant nivolumab plus platinum-based chemotherapy or platinum-based chemotherapy alone, followed by resection. The primary endpoints were event-free survival (EFS) and pCR (24). Adjuvant chemotherapy and/or radiation therapy were optional in this trial, whereas no adjuvant immunotherapy was administered. The median EFS was 31.6 months (95% CI: 30.2 to not reached) with nivolumab plus chemotherapy and 20.8 months (95% CI: 14.0 to 26.7) with chemotherapy alone (HR for disease progression, disease recurrence, or death, 0.63; 97.38% CI: 0.43 to 0.91; P=0.005). The proportion of patients with a pCR was 24.0% (95% CI: 18.0 to 31.0) and 2.2% (95% CI: 0.6 to 5.6), respectively (odds ratio, 13.94; 99% CI: 3.49 to 55.75; P<0.001). It must be noted that EFS was improved in patients who achieved a pCR compared to those who did not. Toxicity was acceptable and not affected by the addition of nivolumab. More specifically, grade 3 or 4 treatment-related adverse events were reported in 33.5% of the patients in the nivolumab plus chemotherapy arm and 36.9% of those in the chemotherapy arm.

The phase III ADAURA trial demonstrated improved DFS with adjuvant osimertinib (third-generation EGFR-TKI) compared to placebo in patients with completely resected stage IB–III NSCLC with an EGFR mutation (25).

Patients with resectable stage II–IIIB N2 EGFR-mutated NSCLC are enrolled in the ongoing phase III NeoADAURA trial, which compares chemotherapy alone to neoadjuvant osimertinib with or without chemotherapy (26).

The IMpower010 trial was the first phase III immunotherapy study to show that adjuvant atezolizumab significantly improved DFS in resected IB–IIIA NSCLC when compared to optimal supportive treatment after platinum-based chemotherapy (HR =0.79; 95% CI: 0.64–0.96; P=0.020). The cohort whose tumors expressed programmed death-ligand 1 (PD-L1) in ≥1% of tumor cells showed significantly better DFS (HR =0.66; 95% CI: 0.50–0.88; P=0.0039). Compared to 11.5% in the chemotherapy-alone arm, 21.8% of patients in the atezolizumab arm experienced grade 3–4 adverse events (27,28). Recently, OS was found to be significantly better in the stage II–IIIA population with PD-L1 expression ≥50% (HR =0.43; 95% CI: 0.24–0.78; P=0.0045) (29).

The randomized, triple-blind, phase III PEARLS/KEYNOTE-091 trial enrolled patients with completely resected, pathologically confirmed stage IB–IIIA NSCLC (30). The patients were randomized to receive adjuvant pembrolizumab versus placebo. Primary endpoints were DFS in the overall population and the population with PD-L1 tumor proportion score (TPS) of 50% or greater. In the overall population, median DFS was 53.6 months (95% CI: 39.2 months to not reached) in the pembrolizumab group versus 42.0 months (95% CI: 31.3 to not reached) in the placebo group [HR 0.76 (95% CI: 0.63–0.91), P=0.0014]. In the PD-L1 TPS of 50% or greater population, median DFS was not reached in either the pembrolizumab group (95% CI: 44.3 to not reached) or the placebo group [95% CI: 35.8 to not reached; HR 0.82 (95% CI: 0.57–1.18); P=0.14]. The investigators concluded that following complete resection, pembrolizumab may be a novel therapy option for stage IB–IIIA NSCLC (30).

KEYNOTE-671 is a randomized phase III trial to evaluate perioperative pembrolizumab in patients with early-stage NSCLC (31). Participants with resectable stage II, IIIA, or IIIB (N2 stage) NSCLC were assigned to receive neoadjuvant pembrolizumab or placebo once every 3 weeks, each of which was given with cisplatin-based chemotherapy for 4 cycles, followed by surgery and adjuvant pembrolizumab or placebo once every 3 weeks for up to 13 cycles. The primary endpoints were EFS and OS. EFS at 24 months was 62.4% in the pembrolizumab group and 40.6% in the placebo group (HR for progression, recurrence, or death, 0.58; 95% CI: 0.46 to 0.72; P<0.001). The estimated 24-month OS was 80.9% in the pembrolizumab group and 77.6% in the placebo group (P=0.02). A major pathological response was observed in 30.2% of the patients in the pembrolizumab group and 11.0% of those in the placebo group pCR was achieved in 18.1% and 4.0%, respectively. In conclusion, the perioperative administration of pembrolizumab significantly improved EFS, major pathological response, and pCR compared to neoadjuvant chemotherapy alone, followed by surgery. On the contrary, OS did not differ significantly between the groups (31).

AEGEAN is a randomized, double-blind, multicenter, placebo-controlled global phase III trial that assessed durvalumab as a perioperative treatment for patients with resectable stage IIA–IIIB NSCLC, regardless of PD-L1 expression (32). The study demonstrated a 32% improvement in EFS and a HR of 0.68. Furthermore, it showed a statistically significant increase in pCR of 17.2% in the perioperative durvalumab arm compared to 4.3% in the placebo group.

A recent meta-analysis of single-arm studies and randomized controlled trials about perioperative immunotherapy demonstrated that patients with resectable NSCLC who received neoadjuvant therapy with ICIs in addition to chemotherapy had increased rates of pCR (OR =7.83; 95% CI: 5.95–10.31; P<0.001) and major pathological response (OR =5.13; 95% CI: 3.56–7.40; P<0.001) than those who received chemotherapy alone (33).

The recently published CheckMate 77T is a randomized, double-blind phase III trial. Patients with resectable stage IIA to IIIB NSCLC were enrolled to receive neoadjuvant nivolumab plus chemotherapy or neoadjuvant chemotherapy plus placebo every three weeks for four cycles, followed by surgery and adjuvant nivolumab or placebo every four weeks for one year (34). The primary outcome was EFS. The proportion of patients with 18-month EFS was 70.2% in the nivolumab group and 50% in the chemotherapy group. A pCR response was achieved in 25.3% of the patients in the nivolumab group compared to 4.7% of patients in the chemotherapy group. A major pathological response was observed in 35.4% and 12.1% of patients, respectively (34).

Conclusions

In conclusion, the recent advances led to a paradigm shift in the treatment of NSCLC. Sublobar resection (wedge, segmentectomy) is a valid treatment for T1a NSCLC measuring less than 2 cm, whereas the recommended treatment for larger tumors remains lobar resection and systematic nodal dissection. Regarding multimodality treatment for resectable NSCLC, the introduction of ICI created a whole spectrum of new treatment algorithms. ICI can be administered in the neoadjuvant, adjuvant, or perioperative setting, yielding excellent results. Final indications for these regimens still have to be established. In the near future, surgical resection will become part of a multimodality treatment protocol, requiring that thoracic surgeons adapt to the new landscape and be involved in future trials.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-21/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-21/coif). J.M.H.H. received funding for cancer research (2 KOTK grants for the study of lung cancer and malignant mesothelioma) and funding from BOF for research in lung transplantation. He declares stocks of medical companies Intuitive and ArgenX but none of them are in conflict with this review. P.E.V.S. received consulting fees, honoraria for lectures and participated in advisory boards for AstraZeneca, BMS, MSD, Roche and Janssen (personal and institutional payments). He is also president of International Association for the Study of Lung Cancer (IASLC) and treasurer of for Belgian Association Cardio-Thoracic Surgery (BACTS). The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-22; discussion 622-3. [Crossref] [PubMed]
2. Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:691-8; discussion 698-700. [Crossref] [PubMed]
3. Chamogeorgakis T, Ieromonachos C, Georgiannakis E, et al. Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients? Interact Cardiovasc Thorac Surg 2009;8:364-72. [Crossref] [PubMed]
4. De Zoysa MK, Hamed D, Routledge T, et al. Is limited pulmonary resection equivalent to lobectomy for surgical management of stage I non-small-cell lung cancer? Interact Cardiovasc Thorac Surg 2012;14:816-20. [Crossref] [PubMed]
5. Kamigaichi A, Hamada A, Tsutani Y. Segmentectomy for patients with early-stage pure-solid non-small cell lung cancer. Front Oncol 2023;13:1287088. [Crossref] [PubMed]
6. Wolf AS, Richards WG, Jaklitsch MT, et al. Lobectomy versus sublobar resection for small (2 cm or less) non-small cell lung cancers. Ann Thorac Surg 2011;92:1819-23; discussion 1824-5. [Crossref] [PubMed]
7. Subramanian M, McMurry T, Meyers BF, et al. Long-Term Results for Clinical Stage IA Lung Cancer: Comparing Lobectomy and Sublobar Resection. Ann Thorac Surg 2018;106:375-81. [Crossref] [PubMed]
8. Li WWL, van der Heide SM, Verhagen AFTM. Extent of Surgery for Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:1629. [Crossref] [PubMed]
9. Altorki N, Wang X, Stinchcombe TE. Extent of Surgery for Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:1629-30. Reply. [Crossref] [PubMed]
10. Winckelmans T, Decaluwé H, De Leyn P, et al. Segmentectomy or lobectomy for early-stage non-small-cell lung cancer: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2020;57:1051-60. [Crossref] [PubMed]
11. Stamatis G, Leschber G, Schwarz B, et al. Perioperative course and quality of life in a prospective randomized multicenter phase III trial, comparing standard lobectomy versus anatomical segmentectomy in patients with non-small cell lung cancer up to 2 cm, stage IA (7th edition of TNM staging system). Lung Cancer 2019;138:19-26.
12. Stamatis G, Leschber G, Schwarz B, et al. Survival outcomes in a prospective randomized multicenter Phase III trial comparing patients undergoing anatomical segmentectomy versus standard lobectomy for non-small cell lung cancer up to 2 cm. Lung Cancer 2022;172:108-16. [Crossref] [PubMed]
13. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet 2022;399:1607-17. [Crossref] [PubMed]
14. Hattori A, Suzuki K, Takamochi K, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer with radiologically pure-solid appearance in Japan (JCOG0802/WJOG4607L): a post-hoc supplemental analysis of a multicentre, open-label, phase 3 trial. Lancet Respir Med 2024;12:105-16. [Crossref] [PubMed]
15. Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:489-98. [Crossref] [PubMed]
16. Brunelli A, Decaluwe H, Gonzalez M, et al. European Society of Thoracic Surgeons expert consensus recommendations on technical standards of segmentectomy for primary lung cancer. Eur J Cardiothorac Surg 2023;63:ezad224. [Crossref] [PubMed]
17. Liu L, Aokage K, Chen C, et al. Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study. JTCVS Open 2023;14:483-501. [Crossref] [PubMed]
18. Ospina AV, Bolufer Nadal S, Campo-Cañaveral de la Cruz JL, et al. Multidisciplinary approach for locally advanced non-small cell lung cancer (NSCLC): 2023 expert consensus of the Spanish Lung Cancer Group GECP. Clin Transl Oncol 2024;26:1647-63. [Crossref] [PubMed]
19. Pignon JP, Tribodet H, Scagliotti GV, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol 2008;26:3552-9. [Crossref] [PubMed]
20. Preoperative chemotherapy for non-small-cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet 2014;383:1561-71. [Crossref] [PubMed]
21. Provencio M, Nadal E, Insa A, et al. Neoadjuvant chemotherapy and nivolumab in resectable non-small-cell lung cancer (NADIM): an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol 2020;21:1413-22. [Crossref] [PubMed]
22. Provencio M, Serna-Blasco R, Nadal E, et al. Overall Survival and Biomarker Analysis of Neoadjuvant Nivolumab Plus Chemotherapy in Operable Stage IIIA Non-Small-Cell Lung Cancer (NADIM phase II trial). J Clin Oncol 2022;40:2924-33. [Crossref] [PubMed]
23. Provencio M, Nadal E, González-Larriba JL, et al. Perioperative Nivolumab and Chemotherapy in Stage III Non-Small-Cell Lung Cancer. N Engl J Med 2023;389:504-13. [Crossref] [PubMed]
24. Forde PM, Spicer J, Lu S, et al. Neoadjuvant Nivolumab plus Chemotherapy in Resectable Lung Cancer. N Engl J Med 2022;386:1973-85. [Crossref] [PubMed]
25. Herbst RS, Wu YL, John T, et al. Adjuvant Osimertinib for Resected EGFR-Mutated Stage IB-IIIA Non-Small-Cell Lung Cancer: Updated Results From the Phase III Randomized ADAURA Trial. J Clin Oncol 2023;41:1830-40. [Crossref] [PubMed]
26. Tsuboi M, Weder W, Escriu C, et al. Neoadjuvant osimertinib with/without chemotherapy versus chemotherapy alone for EGFR-mutated resectable non-small-cell lung cancer: NeoADAURA. Future Oncol 2021;17:4045-55. [Crossref] [PubMed]
27. Felip E, Altorki N, Zhou C, et al. Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase 3 trial. Lancet 2021;398:1344-57. [Crossref] [PubMed]
28. Wakelee HA, Altorki NK, Zhou C, et al. IMpower010: Primary results of a phase III global study of atezolizumab versus best supportive care after adjuvant chemotherapy in resected stage IB-IIIA non-small cell lung cancer (NSCLC). J Clin Oncol 2021;39:8500. [Crossref]
29. Felip E, Altorki N, Zhou C, et al. Overall survival with adjuvant atezolizumab after chemotherapy in resected stage II-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase III trial. Ann Oncol 2023;34:907-19. [Crossref] [PubMed]
30. O’Brien M, Paz-Ares L, Marreaud S, et al. Pembrolizumab versus placebo as adjuvant therapy for completely resected stage IB-IIIA non-small-cell lung cancer (PEARLS/KEYNOTE-091): an interim analysis of a randomised, triple-blind, phase 3 trial. Lancet Oncol 2022;23:1274-86. [Crossref] [PubMed]
31. Wakelee H, Liberman M, Kato T, et al. Perioperative Pembrolizumab for Early-Stage Non-Small-Cell Lung Cancer. N Engl J Med 2023;389:491-503. [Crossref] [PubMed]
32. Heymach JV, Harpole D, Mitsudomi T, et al. Abstract CT005: AEGEAN: A phase 3 trial of neoadjuvant durvalumab + chemotherapy followed by adjuvant durvalumab in patients with resectable NSCLC. Cancer Res 2023;83:CT005. [Crossref]
33. Wu Y, Hu L, Zhang S, et al. The Value of Perioperative Immunotherapy for Non-Small Cell Lung Cancer: A Pool- and Meta-Analysis. Technol Cancer Res Treat 2024;23:15330338241258164. [Crossref] [PubMed]
34. Cascone T, Awad MM, Spicer JD, et al. Perioperative Nivolumab in Resectable Lung Cancer. N Engl J Med 2024;390:1756-69. [Crossref] [PubMed]