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Non-small-cell lung cancer, resectable stage II-IIIA

Non-small-cell lung cancer →

Molecular testing splits the road: without a driver mutation, chemo-immunotherapy comes before surgery and immunotherapy after; with an EGFR or ALK alteration, surgery is followed by a targeted tablet for two to three years.

061 yr182 yr303 yr42Months from diagnosis · solid bar = shortest typical duration, hatched = up to the longest · arrow = continues for yearsPhaseDiagnosis, staging and molecular test…Diagnosis and tests · 3-5 wkNeoadjuvant nivolumab + platinum chem…Before surgery · 9 wkSurgery (lobectomy)Surgery and recovery · 4-6 wkAdjuvant therapyAfter surgery · 12-156 wkSurveillanceSurveillance · yearsIs there an EGFR mutation or ALK fusion?decision 1Diagnosis and testsBefore surgerySurgery and recoveryAfter surgerySurveillance
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Typical sequence for stage II-IIIA (resectable) disease; durations are protocol values (cycle counts and lengths, fraction schedules, guideline follow-up intervals), not averages of real patients. Your team's plan will differ in detail.

Phase by phase

  1. 1. Diagnosis, staging and molecular testing
    weeks 0-5

    CT and PET-CT, brain MRI, biopsy with PD-L1 and a molecular panel (EGFR, ALK, ROS1, KRAS and others), mediastinal staging, lung function tests.

    Source
    Decision: Is there an EGFR mutation or ALK fusion?
    • No driver: neoadjuvant chemo-immunotherapy, surgery, adjuvant immunotherapy
    • EGFR-mutant: surgery first, chemotherapy, then osimertinib for 3 years
    • ALK-positive: surgery first, then alectinib for 2 years
  2. 2. Neoadjuvant nivolumab + platinum chemotherapy (no driver)
    weeks 3-12

    Three 3-week cycles before surgery (CheckMate 816); the KEYNOTE-671 alternative gives four cycles with pembrolizumab.

    Source
  3. 3. Surgery (lobectomy)
    weeks 12-18

    Lobectomy with lymph node dissection 4-6 weeks after the last cycle; often minimally invasive or robotic.

    Source
  4. 4. Adjuvant therapy
    weeks 16-172

    No driver: adjuvant pembrolizumab for 13 cycles (39 weeks, KEYNOTE-671). EGFR-mutant: platinum chemotherapy (12 weeks) then osimertinib for 3 years (ADAURA). ALK-positive: alectinib for 2 years (ALINA).

    Source
  5. 5. Surveillance
    from week 28, continues for years

    CT every 6 months for 2-3 years, then a low-dose CT yearly; smoking cessation support.

    Source

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