Onc hx:

• 12/2025 shoulder pain X ray RUL lung mass
• 12/26/25 CT chest 2.8cm RUL nodule
• 1/23/26 PET/CT with FDG avid RUL nodule, no nodes
• 1/30/26 EBUS with 4R LN positive for adenocarcinoma. Tempus NGS with EGFR L858R. PDL1 TPS 1% 22C3 with CPS 10 but <1% by 28-8, SP142, and SP263. HER2 IHC negative 1+. TMB low 3.7/mb, MSS, IPS high 80%.
• 2/5/26 MRI brain negative for mets
• 2/17/26 LIJ port placement

Dx:

Stage IIB (cT1cN2aM0) RUL NSCLC adenocarcinoma with EGFR L858R

Ref:

• Neoadjuvant Osimertinib for Resectable EGFR-Mutated Non-Small Cell Lung Cancer. J Clin Oncol. 2025 Sep 10;43(26):2875-2887.
• Neoadjuvant Osimertinib: A Step Ahead or Just a Step? J Clin Oncol . 2025 Sep 10;43(26):2847-2850.

Hello this is Miheer (former UMN fellow). I heard you have moved out to AZ - hope you are well and enjoying a warm winter!

I was hoping to run a case by you: I have a 69M nonsmoker with NSCLC adeno that is cT1cN2aM0 based on initial workup (2.8cm RUL mass, PET with no FDG avid nodes but EBUS with a positive 4R node; 4L and 7 nodes negative).

We discussed neoadjuvant chemoimmunotherapy with a plan was to proceed with carbo/pem/nivo per CM816 with the option to add adjuvant nivo per CM77T. Elected not to do cisplatin based on severe baseline hearing loss and borderline renal function, ECOG 1.

NGS now shows EGFR L858R, PDL1 negative (TPS 1% by 22C3 but 0% by all the others), therefore there is no strong rationale for the neoadjuvant ICI approach.

If deemed unresectable, the approach seems fairly straightforward with CRT followed by adjuvant osimertinib per the LAURA trial.

However, if deemed surgically resectable, would you favor:

1. CRT followed by adjuvant osimertinib (LAURA) — nonsurgical but still category 1 per NCCN
2. Chemoradiation followed by surgical resection (if no progression) and adjuvant osimertinib (NCCN) — never seen this done, seems like overtreatment
3. Neoadjuvant chemo/osimertinib followed by surgical resection and adjuvant osimertinib (Neo-ADAURA)
4. Upfront surgery followed by adjuvant chemotherapy and osimertinib (ADAURA)