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Non-small cell lung cancer

Lung Adenocarcinoma

The most common lung cancer. It often starts in the outer lung, is the usual type in never-smokers, and is frequently tested for driver mutations.

15 min read Updated August 28, 2026 3,222 words

Medically reviewed Last reviewed August 28, 2026

Executive Summary

Lung adenocarcinoma is the most common histological subtype of non-small cell lung cancer (NSCLC), accounting for approximately 40–50% of all primary lung malignancies. It arises from the glandular (secretory) epithelial cells lining the distal airways and alveoli. Unlike squamous cell carcinoma, it has a weaker association with heavy smoking and is the predominant type found in never-smokers, women, and younger adults. Modern management is defined by histological subtyping and molecular profiling (EGFR, ALK, ROS1, KRAS, etc.), enabling precision oncology approaches that have significantly improved survival outcomes.

1. Epidemiology & Risk Factors

Key Demographic Shifts

  • Incidence: Rising globally, partly due to screening (LDCT) and changing smoking patterns.
  • Gender: Slightly higher incidence in women compared to men (in never-smoker cohorts).
  • Age: Median age at diagnosis is ~70 years, though molecularly driven subsets (EGFR/ALK+) present younger (median 50–60 years).

Risk Factor Stratification

Risk Category Specific Factors Relative Risk / Notes
Tobacco Smoke Active smoking (current/former) Dose-dependent. Risk persists decades after cessation. Adenocarcinoma is now the most common type in smokers (surpassing squamous).
Environmental Radon gas (2nd leading cause), Asbestos, Arsenic, Chromium, Nickel, Air pollution (PM2.5) Synergistic effect with smoking (multiplicative risk).
Genetic/Host Family history (1st degree relative), GERD (chronic microaspiration), Prior radiation therapy (breast/lymphoma) Germline mutations (e.g., EGFR T790M, BRCA2) are rare but documented.
Infectious/Inflammatory HIV infection, Chronic obstructive pulmonary disease (COPD), Pulmonary fibrosis (IPF), Tuberculosis scarring Chronic inflammation drives mutagenesis.
Dietary/Lifestyle Low fruit/vegetable intake, Beta-carotene supplements (in smokers) Note: Beta-carotene supplementation increases risk in current smokers (ATBC/CARET trials).

Clinical Pearl: A “never-smoker” is defined as someone who has smoked < 100 cigarettes in their lifetime**. In this group, adenocarcinoma represents >80% of lung cancers.

2. Pathology & Histological Classification (WHO 2021/5th Edition)

The current classification abandons the old “Bronchioloalveolar Carcinoma (BAC)” terminology. It emphasizes invasive pattern quantification (lepidic, acinar, papillary, micropapillary, solid) because the highest-grade pattern predicts prognosis.

Invasive Adenocarcinoma: Growth Patterns & Prognostic Hierarchy

Growth Pattern Architectural Description Grade / Prognosis Key Diagnostic Feature
Lepidic Tumor cells grow along intact alveolar septa (“non-invasive” growth). Low Grade (Best prognosis) ≥ 5mm lepidic component required for “AIS” or “MIA” distinction.
Acinar Glandular/tubular structures. Intermediate Grade Most common pattern.
Papillary Fibrovascular cores lined by tumor cells. Intermediate Grade Distinct papillae; can mimic metastatic papillary thyroid/renal.
Micropapillary Small papillary clusters floating in air spaces without fibrovascular cores. High Grade (Poor prognosis) Strong predictor of lymphovascular invasion & recurrence.
Solid Sheets of cells with no glandular formation. High Grade (Poor prognosis) Must rule out solid-predominant vs. large cell carcinoma (immunostains needed).
Cribriform Glands with “swiss cheese” holes (back-to-back glands). High Grade (New distinct pattern) Associated with TP53 mutations, poor outcome.

Pre-Invasive & Minimally Invasive Lesions

Entity Size Criteria Invasion 5-Yr Disease-Free Survival
AIS (Adenocarcinoma In Situ) ≤ 3 cm Pure lepidic, NO stromal/tissue/vascular invasion ~100% (if completely resected)
MIA (Minimally Invasive Adenocarcinoma) ≤ 3 cm Predominantly lepidic + Invasion ≤ 5 mm (single focus) ~98–100%
Invasive Adenocarcinoma Any size Invasion > 5 mm or high-grade patterns present Variable (Stage dependent)

Immunohistochemistry (IHC) Panel for Lineage Confirmation

  • Positive (Adenocarcinoma markers): TTF-1 (NKX2-1), Napsin A (High specificity).
  • Negative (Squamous markers): p40, p63, CK5/6.
  • Utility: Essential for small biopsies/cytology where architecture is obscured. TTF-1 is also positive in thyroid carcinoma; use Thyroglobulin/PAX8 to exclude metastasis.

3. Molecular Landscape: The Engine of Precision Medicine

Molecular testing is mandatory standard of care for all advanced (Stage IV) non-squamous NSCLC and strongly recommended for early-stage resected specimens (to guide adjuvant therapy).

Actionable Driver Mutations (Oncogenic Addiction)

Gene / Alteration Frequency (Adenocarcinoma) Population Enrichment FDA-Approved 1st Line TKIs Resistance Mechanisms
EGFR (Exon 19 del, L858R) 10–15% Caucasians<br>30–50% Asians Never-smokers, Female, Asian Osimertinib (Standard), Gefitinib, Erlotinib, Afatinib, Dacomitinib T790M (historical), C797S, MET amp, Histologic transformation (SCLC).
ALK Rearrangement 3–5% Never/light smokers, Younger (<50) Lorlatinib, Alectinib, Brigatinib, Ensartinib, Crizotinib Kinase domain mutations (L1196M, G1202R), Bypass tracks.
ROS1 Rearrangement 1–2% Similar to ALK Entrectinib, Repotrectinib, Crizotinib G2032R (solvent front), MET amp.
BRAF V600E Mutation 1–2% Smokers (unlike EGFR/ALK) Dabrafenib + Trametinib (Dual BRAF/MEK inhibition) MEK mutations, NRAS mutations.
KRAS G12C Mutation ~13% Smokers Sotorasib, Adagrasib KRAS amplification, MAP2K1/MEK mutations, PI3K pathway.
MET Exon 14 Skipping 3–4% Older, often smokers Capmatinib, Tepotinib MET amplification, KRAS mutations.
RET Rearrangement 1–2% Never-smokers Selpercatinib, Pralsetinib V804 gatekeeper mutations.
NTRK 1/2/3 Fusion < 1% Any histology, rare Larotrectinib, Entrectinib TRK kinase domain mutations.
HER2 (ERBB2) Exon 20 Ins / Mut 2–4% Never-smokers, Female Trastuzumab Deruxtecan (T-DXd), Pyrotinib Heterogeneity, TP53 co-mutation.
EGFR Exon 20 Insertions ~2–3% of EGFR+ Never-smokers Amivantamab, Mobocertinib (US withdrawal), Sunvozertinib (China) Distinct from classical EGFR; resistant to 1st/3rd gen TKIs.

Immunotherapy Biomarkers

  • PD-L1 Expression (TPS – Tumor Proportion Score):
  • TPS ≥ 50%: Single-agent Pembrolizumab (or Cemiplimab) is standard 1st line (KEYNOTE-024/042).
  • TPS 1–49%: Pembrolizumab + Chemotherapy preferred over chemo alone (KEYNOTE-189).
  • TPS < 1%: Chemo + Immunotherapy (Pembrolizumab/Bevacizumab/Atezolizumab combos) or Chemo alone.
  • Tumor Mutational Burden (TMB): High TMB (≥10 mut/Mb) historically used for pembrolizumab approval (KEYNOTE-158), but not currently a primary decision biomarker for 1st line NSCLC per NCCN/ESMO.
  • STK11 / KEAP1 Co-mutations: Associated with primary resistance to PD-1 inhibitors in KRAS-mutant tumors (“cold” microenvironment).

Testing Strategy: Broad NGS Panel (DNA + RNA) is superior to sequential single-gene testing (PCR/FISH/IHC). RNA-based NGS is critical for detecting fusions (ALK, ROS1, RET, NTRK) and MET exon 14 skipping. Turnaround time target: < 14–21 days**.

4. Clinical Presentation & Diagnosis

Symptom Profile

Category Symptoms Mechanism
Local (Central/Peripheral) Cough (new/change), Hemoptysis, Dyspnea, Chest pain (pleural involvement) Airway irritation, tumor erosion, pleural invasion.
Constitutional Weight loss (>10% in 6mo), Anorexia, Fatigue, Fever (paraneoplastic) Cytokine release (TNF-α, IL-6), metabolic demand.
Locoregional Spread Hoarseness (Recurrent laryngeal n.), SVC Syndrome (facial edema), Pancoast Syndrome (shoulder/arm pain, Horner’s) Mediastinal invasion, Brachial plexus/Subclavian vessel involvement.
Distant Metastases Bone pain, Headache/Seizures (Brain), Jaundice (Liver), Adrenal insufficiency Hematogenous spread. Brain mets at dx: ~20-25% (higher in EGFR/ALK+).
Paraneoplastic SIADH (Hyponatremia), Lambert-Eaton (Proximal weakness), Hypercalcemia (PTHrP), Digital clubbing (HPOA) Ectopic hormone/antibody production.

Diagnostic Workup Algorithm

  1. Imaging:
  • Contrast-enhanced CT Chest/Upper Abdomen (Liver/Adrenals).
  • PET-CT (FDG): Standard for staging (Stage IB–III). Note: AIS/MIA and carcinoids can be FDG-negative.
  • Brain MRI (Contrast): Mandatory for Stage III/IV and surgical candidates (Stage I/II) due to high occult brain metastasis rate.
  1. Tissue Acquisition (Hierarchy of Yield):
  • EBUS-TBNA / EUS-B-FNA: Mediastinal nodal staging + diagnosis (High yield, low morbidity).
  • CT-Guided Core Needle Biopsy: Peripheral lesions (>90% yield for >2cm). Risk: Pneumothorax (15–25%), Hemorrhage.
  • Bronchoscopy (Navigational/Robotic): For central/peripheral lesions; allows airway inspection.
  • Liquid Biopsy (ctDNA / Plasma NGS): Complementary only. High specificity, low sensitivity (~60–75%). Cannot replace tissue biopsy for initial diagnosis (insufficient tissue for IHC/PD-L1/RNA-fusion). Useful for resistance monitoring.
  1. Pathology Processing: Rapid On-Site Evaluation (ROSE) improves adequacy. Tissue triage: Histology → IHC → Molecular (NGS).

5. Staging: TNM 8th Edition (AJCC/UICC) & Stage Groups

Staging dictates treatment intent (Curative vs. Palliative) and clinical trial eligibility.

Primary Tumor (T)

T Category Criteria
Tis AIS / MIA
T1 ≤ 3 cm (T1a ≤1, T1b >1–2, T1c >2–3)
T2 >3 – ≤5 cm OR involves main bronchus (≥2cm from carina), visceral pleura (PL1/2), atelectasis/obstructive pneumonitis to hilum.
T3 >5 – ≤7 cm OR Direct invasion: Chest wall, Phrenic nerve, Pericardium (parietal), Separate tumor nodule same lobe.
T4 >7 cm OR Invasion: Diaphragm, Mediastinum, Heart, Great vessels, Trachea, Recurrent laryngeal n., Esophagus, Vertebra, Carina. OR Separate tumor nodule different ipsilateral lobe.

Regional Nodes (N)

N Category Criteria
N0 No regional nodal metastasis.
N1 Ipsilateral peribronchial / hilar nodes (Stations 10–14).
N2 Ipsilateral mediastinal / subcarinal nodes (Stations 1–9).
N3 Contralateral mediastinal/hilar/supraclavicular OR Ipsilateral supraclavicular (Station 1).

Distant Metastasis (M)

M Category Criteria
M0 No distant metastasis.
M1a Separate tumor nodule contralateral lung; Pleural/Pericardial nodules or Malignant effusion.
M1b Single extrathoracic metastasis (Single organ).
M1c Multiple extrathoracic metastases (Single or Multi-organ).

Stage Grouping (Simplified)

Stage T N M Typical Treatment Intent
0 Tis N0 M0 Curative (Sublobar resection / Ablation)
IA T1a/b/c N0 M0 Curative (Surgery ± Adjuvant)
IB T2a N0 M0 Curative (Surgery ± Adjuvant Chemo if high risk)
IIA T2b N0 M0 Curative (Surgery + Adjuvant Chemo)
IIB T1–2a / T3 N1 / N0 M0 Curative (Surgery + Adjuvant Chemo ± Immunotherapy)
IIIA T1–2 / T3–4 N2 / N1 M0 Multimodal (Chemoradiation ± Surgery ± Immunotherapy)
IIIB T3–4 / T1–2 N2 / N3 M0 Definitive Chemoradiation + Consolidation Immunotherapy
IIIC T3–4 N3 M0 Definitive Chemoradiation + Consolidation Immunotherapy
IVA Any Any M1a/b Palliative / Chronic Control (Systemic Therapy ± Local RT)
IVB Any Any M1c Palliative / Chronic Control (Systemic Therapy)

Critical Concept: “Oligometastatic Disease” (M1b). 1–3–5 metastatic lesions. Aggressive local therapy (SBRT/Surgery) to all sites + Systemic therapy may** yield long-term survival / potential cure in selected patients (EGFR/ALK+ especially). Discuss in Multidisciplinary Tumor Board.

6. Management by Stage

Stage I–II (Early Stage) – Surgical Candidates

Standard: Anatomic Lobectomy + Systematic Mediastinal Lymph Node Dissection (MLND).

  • Sublobar Resection (Segmentectomy): Non-inferior to lobectomy for T1a/b N0 (≤2cm), pure AIS/MIA, or GGO-predominant (>50%) (JCOG0802, CALGB 140503). Anatomic segmentectomy preferred over wedge.
  • Lymph Node Assessment: MLND (removal of stations 2, 4, 7, 8, 9, 10) > Sampling. Minimum 3 N2 stations sampled.
  • Minimally Invasive (VATS/RATS): Standard of care. Equivalent oncology outcomes, less pain, faster recovery.

Adjuvant Therapy Decision Matrix (Post-Resection, N0–N1)

Stage / Risk Factor Standard Adjuvant Novel Adjuvant (Biomarker Driven)
IA (T1a–c N0) Observation (No chemo) Osimertinib (ADAURA): Stage IB–IIIA EGFRm (Ex19del/L858R). 3 years. DFS HR 0.17. OS benefit confirmed.
IB (T2a N0) High Risk<br>(Poor diff, VPI, LVI, >4cm, wedge) Consider Platinum Doublet (Cisplatin/Vinorelbine x 4 cycles). Discuss risk/benefit. Clinical Trials (e.g., ALINA: Alectinib for ALK+).
IIA–IIB (T2b–3 N0 / T1–2 N1) Platinum Doublet Chemo x 4 cycles (Cisplatin preferred). Atezolizumab (IMpower010): Stage II–IIIA PD-L1 ≥ 1% (TC/IC) after chemo. DFS benefit. OS trend. <br> Pembrolizumab (PEARLS/KEYNOTE-091): All comers Stage IB–IIIA (DFS benefit marginal in PD-L1 neg).
IIIA (N2) Neoadjuvant preferred (see below). If upfront surgery → Adjuvant Chemo ± RT ± Immuno. Neoadjuvant Nivolumab + Chemo (CheckMate 816) → Surgery → Adjuvant Nivo (CheckMate 77T) is new standard for resectable II–IIIB.

Stage III (Locally Advanced) – Unresectable / Borderline

Standard: Concurrent Chemoradiation (cCRT) → Consolidation Durvalumab (PACIFIC Regimen).

  • Radiation: 60–66 Gy / 30–33 fractions. Proton therapy considered for cardiac sparing.
  • Chemo: Cisplatin/Etoposide or Carboplatin/Paclitaxel (weekly) concurrent.
  • Consolidation Durvalumab: Start 1–42 days post-RT. 10 mg/kg q2wk x 12 months. OS benefit regardless of PD-L1 (though magnitude higher in PD-L1 ≥ 25%).
  • EGFRm/ALK+ Stage III: PACIFIC benefit unclear (excluded/underrepresented). Standard remains cCRT. LAURA Trial (Osimertinib post-cCRT for EGFRm): Positive PFS/OS. Practice changing.

Stage IV (Metastatic) – Systemic Therapy is Backbone

Goal: Prolong survival, maintain Quality of Life (QoL), symptom control.

1st Line Treatment Algorithm (Simplified)

Molecular Subgroup Preferred 1st Line Regimen Key Trial / Evidence
EGFR Ex19del / L858R Osimertinib (Monotherapy) FLAURA / FLAURA2 (Osi+Chemo improves PFS, OS immature).
EGFR Exon 20 Ins Amivantamab + Chemo (Carbo/Pem) PAPILLON (OS/PFS benefit). Mobocertinib (2nd line/accelerated approval withdrawn US).
ALK+ Lorlatinib OR Alectinib / Brigatinib / Ensartinib CROWN (Lorlatinib: CNS penetration, PFS not reached).
ROS1+ Entrectinib OR Repotrectinib (if CNS mets) / Crizotinib TRIDENT-1 (Repotrectinib active post-TKI & G2032R).
BRAF V600E Dabrafenib + Trametinib BRF113928 (High ORR, durable).
KRAS G12C Sotorasib OR Adagrasib (Monotherapy) OR Chemo-Immuno CodeBreaK 200 / KRYSTAL-1. Note: Chemo-Immuno often used 1st line due to broader efficacy; TKIs approved 2nd line+ (US) / 1st line (EU/China variations). Evolving space.
MET Ex14 Skip Capmatinib OR Tepotinib GEOMETRY / VISION.
RET+ Selpercatinib OR Pralsetinib LIBRETTO / ARROW.
NTRK Fusion Larotrectinib OR Entrectinib NAVIGATE / STARTRK-2.
HER2 Mut (Ex20 Ins) Trastuzumab Deruxtecan (T-DXd) DESTINY-Lung02 (Breakthrough Therapy).
No Driver (Wild Type / KRAS non-G12C / etc.) PD-L1 TPS ≥ 50%: Pembrolizumab ± Chemo (KEYNOTE-024/598).<br>PD-L1 1–49%: Pembrolizumab + Chemo (KEYNOTE-189).<br>PD-L1 < 1%: Pembrolizumab + Chemo OR Atezolizumab + Bev + Chemo (IMpower150 – non-squamous) OR Chemo alone. Chemo Backbone: Pemetrexed + Platinum (Cis/Carbo) is standard for non-squamous.

Maintenance & Subsequent Lines

  • Maintenance: Continue Immunotherapy (until progression/toxicity 2yrs) ± Pemetrexed (if non-squamous, non-progressing after 4–6 cycles chemo-immuno).
  • Progression on Targeted Therapy: Biopsy (Tissue or Liquid) mandatory to define resistance mechanism (e.g., EGFR C797S, MET amp, SCLC transformation). Guide next targeted agent or switch to Chemo-Immuno.
  • Progression on Immunotherapy: Docetaxel ± Ramucirumab; Docetaxel + Nintedanib (adeno specific); T-DXd (if HER2 mut); Clinical Trials.

Local Therapy in Stage IV

  • Brain Mets: SRS (Stereotactic Radiosurgery) preferred over WBRT (preserves neurocognition). Osimertinib/Lorlatinib/Entrectinib have high CNS penetration – may defer RT in asymptomatic small mets.
  • Oligoprogression: Local ablative therapy (SBRT/Surgery) to progressing site while continuing effective systemic therapy.

7. Management of Toxicities (High-Yield for Patient Safety)

Drug Class / Agent Key Toxicity Monitoring / Management
EGFR TKIs (Osimertinib) Diarrhea, Rash, Paronychia, QTc Prolongation, ILD/Pneumonitis (~3%) Loperamide PRN; Doxycycline prophylaxis for rash?; Baseline & Serial ECG + Electrolytes (K+/Mg2+); Hold for Gr≥2 ILD (CT chest), permanent DC if confirmed.
ALK TKIs (Lorlatinib/Alectinib) Hyperlipidemia (Lorla), Weight gain/Edema, CPK elev, Bradycardia, ILD (<2%), Cognitive effects (Lorla) Fasting Lipid Panel q4-8wks (Statin ready); CK monitoring; ECG; Neurocognitive screen.
KRAS G12C Inhibitors Hepatotoxicity (ALT/AST), Diarrhea, Nausea, ILD (~1-2%) LFTs q3wks x 8wks then q4-8wks; Hold for Gr≥3.
MET Inhibitors Peripheral Edema (very common), Hypoalbuminemia, Nausea, Creatinine elev (c-MET on tubules) Diuretics, Compression stockings, Dietary protein; Monitor Cr/Alb.
T-DXd (HER2) ILD/Pneumonitis (~10-15%, fatal ~1-2%), Nausea, Thrombocytopenia Strict ILD monitoring (Baseline CT, q3-4mo / symptom); Prophylactic antiemetics (NK1+5HT3+Dex); CBC q cycle.
Immunotherapy (PD-1/PD-L1) Immune-Related Adverse Events (irAEs): Thyroiditis, Pneumonitis, Colitis, Hepatitis, Hypophysitis, Dermatitis, Myocarditis (rare/fatal), Neurological. Baseline TSH/fT4, LFTs, Creatinine, Cortisol (AM). Educate patient: “New symptom = Call Oncology.” Steroids (Pred 1-2mg/kg) for Gr≥2; Infliximab for steroid-refractory colitis/hepatitis. DO NOT TAPER FAST (4-6 wks).
Chemotherapy (Platinum/Pemetrexed) Neutropenia (Febrile), Neuropathy (Platinum), Ototoxicity, Nephrotoxicity, Fatigue. Pemetrexed: Mandatory Folic Acid + B12 Injection + Dexamethasone premed. G-CSF primary prophylaxis if dose-dense / high risk.

8. Survivorship, Follow-Up & Quality of Life

Surveillance Schedule (Post-Curative Intent Therapy – NCCN/ESMO Guidelines)

Timeframe History & Physical Chest CT (Contrast preferred) Brain MRI Labs / Other
Years 1–2 Every 6 Months Every 6 Months Annually (High risk: EGFR/ALK+, Stage III, prior brain mets) CBC, CMP, TSH (if prior IO), Vit D.
Years 3–5 Every 6–12 Months Every 6–12 Months Annually (if indicated) As above.
Year 5+ Annually Annually (Consider Low-Dose CT) As clinically indicated Age-appropriate screening.

Critical Survivorship Issues

  1. Second Primary Lung Cancer Risk: 1–2% per year. Lifelong annual LDCT recommended.
  2. Cardiotoxicity: Radiation (ischemic heart disease, valvular), Anthracyclines (rare in lung), TKIs (QTc, HF). Baseline Echo + Strain imaging; Risk factor modification (Statins, BP control).
  3. Pulmonary Function: Post-lobectomy FEV1 loss ~15-20%. Pulmonary Rehab mandatory pre/post-op.
  4. Financial Toxicity: Oral TKIs ($15k–$20k/mo). Connect with Patient Assistance Programs (PAP), Copay Foundations, Social Work early.
  5. Mental Health: Distress screening (NCCN Distress Thermometer) at every visit. Fear of recurrence, scanxiety.
  6. Smoking Cessation: Active intervention improves survival even after diagnosis. Pharmacotherapy (Varenicline) + Counseling.

9. Emerging Horizons (2024–2025+)

  • Antibody-Drug Conjugates (ADCs) in Earlier Lines: T-DXd (HER2, TROP2), Dato-DXd (TROP2), Patritumab Deruxtecan (HER3) – moving from 2nd/3rd line to 1st line combinations.
  • Bispecific Antibodies: Amivantamab (EGFRxMET), Ivonescimab (PD-1xVEGF), Tebotelimab (PD-1xLAG-3). Overcoming resistance.
  • Neoadjuvant/Adjuvant Immunotherapy Expansion: CheckMate 77T (Nivo+Chemo → Surg → Nivo) and KEYNOTE-671 (Pembro+Chemo → Surg → Pembro) show Event-Free Survival (EFS) and OS benefits for resectable Stage II–IIIB (N2). New Standard of Care.
  • ctDNA MRD (Molecular Residual Disease): Post-op/surgery ctDNA positivity = High relapse risk. Trials testing ctDNA-guided adjuvant therapy (de-escalation if negative, escalation if positive) – DYNAMIC, IMPACT-Lung, MERMAID-1.
  • KRAS Non-G12C Inhibitors: Pan-KRAS inhibitors, KRAS(ON) multi-specific inhibitors.
  • CNS Penetration Optimization: Next-gen TKIs (e.g., Zongertinib for HER2, Zidesamtinib for MET) designed for brain mets.

10. Patient & Caregiver Quick-Reference Checklist

  • [ ] Confirm Histology: “Non-squamous NSCLC – Adenocarcinoma” on pathology report.
  • [ ] Molecular Testing Ordered: Broad NGS Panel (Tissue + Plasma) sent before 1st treatment. Ask: “Is PD-L1 tested?”
  • [ ] Brain MRI Done: Before starting systemic therapy (if Stage III/IV).
  • [ ] Biomarker Card: Carry a wallet card listing: Driver Mutation (e.g., EGFR Ex19del), PD-L1 %, Current Therapy, Allergies, Oncologist Contact.
  • [ ] Supportive Care Referral: Palliative Care / Supportive Oncology at diagnosis (Stage IV) – Proven Survival Benefit (Temel et al., NEJM 2010).
  • [ ] Clinical Trial Screen: Ask at every decision point: “Is there a clinical trial for my specific mutation/situation?”
  • [ ] Vaccinations: Inactivated (Flu, COVID, Pneumococcal, RSV, Shingles recombinant) – Safe/Encouraged. Avoid Live Vaccines during chemo/immunotherapy/high-dose steroids.
  • [ ] Advanced Directives: Discuss Goals of Care, Healthcare Proxy, MOLST/POLST forms early.

11. Glossary of Key Acronyms

Acronym Full Term
ADC Antibody-Drug Conjugate
AIS Adenocarcinoma In Situ
ALK Anaplastic Lymphoma Kinase
ctDNA Circulating Tumor DNA
cCRT Concurrent Chemoradiation
CNS Central Nervous System
DFS Disease-Free Survival
ECOG PS Eastern Cooperative Oncology Group Performance Status (0–5)
EGFR Epidermal Growth Factor Receptor
EBUS Endobronchial Ultrasound
FDG-PET Fluorodeoxyglucose Positron Emission Tomography
GGO Ground-Glass Opacity
HR Hazard Ratio
ILD Interstitial Lung Disease (Pneumonitis)
IHC Immunohistochemistry
LDCT Low-Dose Computed Tomography
MIA Minimally Invasive Adenocarcinoma
MRD Molecular Residual Disease
NGS Next-Generation Sequencing
NSCLC Non-Small Cell Lung Cancer
ORR Objective Response Rate
OS Overall Survival
PFS Progression-Free Survival
PS Performance Status
RT Radiation Therapy
SBRT Stereotactic Body Radiation Therapy
SRS Stereotactic Radiosurgery
TKI Tyrosine Kinase Inhibitor
TPS Tumor Proportion Score (PD-L1)
VATS Video-Assisted Thoracoscopic Surgery
VEGF Vascular Endothelial Growth Factor
WBRT Whole Brain Radiation Therapy

References (Harvard Style)

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  2. Bristol Myers Squibb (2023) CheckMate 816 & 77T: Neoadjuvant/Adjuvant Nivolumab in Resectable NSCLC. Available at: https://www.bms.com (Accessed: 15 October 2023).
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  7. Mok, T.S. et al. (2022) ‘Osimertinib with or without Chemotherapy in EGFR-Mutated Advanced NSCLC (FLAURA2)’, The New England Journal of Medicine, 387(23), pp. 2135–2148. https://doi.org/10.1056/NEJMoa2211546.
  8. Paz-Ares, L. et al. (2023) ‘Pembrolizumab plus Chemotherapy versus Chemotherapy Alone for First-Line Treatment of Advanced NSCLC (KEYNOTE-189): 5-Year Update’, Journal of Clinical Oncology, 41(16_suppl), pp. 8500–8500. https://doi.org/10.1200/JCO.2023.41.16_suppl.8500.
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Disclaimer: This article is intended for educational and informational purposes only. It does not constitute medical advice, diagnosis, or treatment recommendations. Clinical decisions must be made by a qualified multidisciplinary team (Medical Oncology, Thoracic Surgery, Radiation Oncology, Pulmonology, Pathology, Radiology) based on individual patient factors, comorbidities, performance status, and current guideline updates.