Johan Pluvy Highlights ESMO 2025 NSCLC Guidelines
Johan Pluvy, Pulmonologist-oncologist Hospital Practitioner at APHM, shared a post on X about a paper by A. Zer et al. published on ESMO Annals of Oncology:
“1/ New ESMO 2025 recommendations for early/locally advanced NSCLC published in Annals of Oncology. Focus on surgical, perioperative and unresectable stage III advances.
2/ LD-CT screening recommended for smokers ≥30 PA (or ex-smokers <15 years of quitting), 55–74 years old. Mention of pilot programs for non-smokers at risk (passive exposure, family history).
3/ Diagnosis Biopsy/pathology mandatory for ALL stages I–III (if technically feasible). Multidisciplinary to choose the approach (broncho/EBUS/transthoracic). End of ‘direct surgical diagnosis’ except in very specific situations.
4/ Surgery 2017: lobectomy = gold standard. 2025: Sublobar validated (segmentectomy) for peripheral tumors ≤2 cm. VATS/RATS recommended. Apex (Pancoast tumors): no change, neoadj CRT + surgery, but now durvalumab possible after CRT.
5/ EGFR, ALK, PD-L1 biomarkers mandatory in stages IB–III. ctDNA / MRD = prognosis, not yet to guide intensification or de-escalation.
6/ Targeted adjuvants Osimertinib 3 years (EGFR exon19/L858R) = SoC (improved OS, ADAURA). Alectinib 2 years (ALK+) = SoC (ALINA).
7/ Immunotherapy (EGFR/ALK WT) Nivolumab + chemo (CheckMate 816 / 77T). Pembrolizumab (KEYNOTE-671). Durvalumab (AEGEAN).
8/ Unresectable Stage III Concomitant CRT = SoC (60–66 Gy + platinum). Sequential CRT: for fragile patients. Consolidation: Durvalumab if EGFR WT, PD-L1 ≥1% possible in sequential New: Osimertinib consolidation in EGFR+ (LAURA, PFS 39.1 vs 5.6 months).
9/ ILD (interstitial lung disease) Expert assessment of ILD recommended before any therapeutic decision. Shared decision-making is essential because of increased risks with surgery, RT and IO.
10/ Thoracic CT + adrenal follow-up every 6 months × 2 years, then annually up to 5 years. Intensified (3–6 months) if high risk and eligible for catch-up.
11/ In summary – Key changes since 2017
- Reinforced LD-CT screening.
- Mandatory biopsy before any therapeutic decision (I–III).
- Sublobar validated for ≤2 cm.
- Adjuvant TKIs: osimertinib (EGFR+), alectinib (ALK+).
- Peri-op chemo-IO = standard in EGFR/ALK WT.
- Sequential CRT recognized as an option for fragile patients.
- Osimertinib consolidation if EGFR+ stage III unresectable.
- Integrated ILD management (expert assessment).
- Apex: no change, except possible addition of durvalumab after CRT.”
Title: Early and locally advanced non-small-cell lung cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up
Authors: A. Zer, M.-J. Ahn, F. Barlesi, L. Bubendorf, D. De Ruysscher, P. Garrido, O. Gautschi, L.E. Hendriks, P.A. Jänne, K.M. Kerr, C. Mascaux, T. Mitsudomi, S. Peters, C. Rolfo, A. Sacher, S. Senan, P. Ugalde, N.B. Leighl
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