Chapters Transcript Video Early Stage Disease: Panel Discussion and Case Studies All right, we're really late. We do have a case, but I'm gonna ask that we bypass the case, uh, so open to a couple of quick questions, um, so that we can uh try to get back online, uh, on time. Uh, yes, Doctor Arusha. Dr. Sue, you commented a lot about the primary lesions, very little said about the mediastinal node dissections which in terms of decision making is probably the most critical, uh, aspect that we look at. It is true that I'm, um, taking, um, for granted that patients are properly staged at the outset, and that is absolutely critical that patients be appropriately sampled in the relevant lymph node stations both in the hyla and in the mediastinum. I take that for granted, being that we work with great colleagues who, who get that done, but you're absolutely right, Doctor Betch. Corey. I have a question actually, well, for Doctor Bodder but maybe for the entire audience for EGFR and ALC, do we need platinum-based, uh, adjuvant? Uh, uh, it was not even used in the, uh, ALCA, the, uh, um, electinib arm in the AIA trial is optional in Adora. Uh, do you think that's a bona fide study question or should we go on to other things? I mean, certainly, I think it's a bona fide study question. I mean, what I will say is in my current practice, I still favor giving the chemotherapy largely because of the overall survival benefit that's been well established from all the, the prior meta analysis, in particular the lace meta analysis. And I think the other thing too is I think not every EGFR or ALC-driven lung cancer are necessarily uh the same. There are some that are probably like we've learned in the medicine. setting there's some phenotypes that are probably more high risk uh for um resistance to our targeted therapies or even potentially relapse um after a definitive therapy um than others in particular again to kind of go back where we're talking about as far as, you know, TP53 co mutations or perhaps even the subtypes of, of the particular oncogene. So with all that in mind, I, I. Don't necessarily think that just the targeted therapy in itself is, is what I, I'm, I'm fully comfortable with at this current time. I still favor giving the adjuvant chemotherapy. And the last thing I'll say about this too is unlike with chemo immunotherapy where I think we have the potential of actually curing patients, I still have that question of whether or not we're actually curing these patients with targeted therapy or just kind of suppressing um, uh, you know, minimal disease. Question, uh, question for Doctor Sue, uh, when it comes to, uh, surgery following, uh, um. A new adjuvant therapy, do you find the surgery itself is more difficult, the resection is more difficult because there is more fibrosis, etc. or is it the same whether it is, uh, chemo immunotherapy naive or not? There, there is no question it's, it's fraught with um risks, uh, the, um. The degree of, you know, especially in these tumors that get the neoadjuvant chemoimmunotherapy, they're usually bulky, you know, hilar, uh, added with bulky hilar adenopathy. And so, um, there are extra steps that we take in the operating room to prepare, um, for, you know, conversion from a robotic approach to an open thoracotomy, you know, uh, reserving blood products. In advance, getting around the main pulmonary artery in case of massive hemorrhage, there are certain moves that we, um, anticipate, uh, making for such cases, and there, there's no question that, that the chemo immunotherapy, much as it gives great pathologic response, you know, comes at a cost to the surgeon and to the patient. One last question, Rosa. Um, question for Dr. Lang. Um, for the approximately 20% of patients in the new adjuvant per patient, um, studies that do not progress to surgery for whatever reason. Um, and you like you presented, don't do well. Do we have a way of predicting who these patients will be? We need to figure that out. We really need to go back to these trials, look very closely at the baseline demographics of that group where those patients were treated, uh, with the surgical expertise of those institutions where, you know, we think all Doctor Sue can tell you that, uh, not all surgeons are alike, uh, you know, uh, when it comes to Epinivo or chemo Nvo, the drug doses, things are a little bit more uniform. Uh, so I, I worry about that, but it's consistent. Every single one of those studies has shown the same general trend. Um, half or more, I suspect may have been aspirational. I mean, clearly there's toxicity that some of these patients develop horrible immunotherapy side effects that just make surgery untenable, um, and then some may have some hidden comorbidities that come out. Um, you've lost the opportunity to cure those patients if they don't go on to definitive local treatment. There's no question. We think many of them will default to radiation or chemo radiation, but even there we need more data and the, the trend in all of those studies has been for inferior outcome compared to, uh, what we would accept with Pacific, frankly, even going back to the 0617 era, the pre-IO era. So a lot more needs to be determined. I, uh, if, uh, multidisciplinary decision making is key, if the surgeon is not sure that they're going to get this patient. To an operation after um neoadjuvant in our institution, we will generally favor chemo radiation upfront. So we'll go with the Pacific one approach preferentially, and I really think, uh, that may be the best way to go in such patients. Thank you. Uh, again, thank you everybody. Created by
