What is the recommended treatment for patients with ALK (Anaplastic Lymphoma Kinase)-positive or EGFR (Epidermal Growth Factor Receptor)-mutated adenocarcinoma of the lung with a positive 10R lymph node?

From the Guidelines

For patients with ALK-positive or EGFR-mutated adenocarcinoma of the lung with a positive 10R lymph node, the recommended treatment approach is surgical resection followed by adjuvant targeted therapy, with alectinib or lorlatinib for ALK-positive tumors and osimertinib for EGFR-mutated tumors, as supported by the most recent guidelines 1. The treatment of ALK-positive or EGFR-mutated adenocarcinoma of the lung with a positive 10R lymph node involves a multidisciplinary approach, including surgery, targeted therapy, and surveillance.

• Surgical resection is the primary treatment for stage IIIA disease, with the goal of achieving complete resection of the tumor and involved lymph nodes.
• Adjuvant targeted therapy is recommended after complete surgical resection to reduce the risk of recurrence and improve overall survival.
• For ALK-positive tumors, alectinib (600 mg twice daily) or lorlatinib (100 mg once daily) are recommended for 3 years, based on their efficacy in improving progression-free survival and overall survival 1.
• For EGFR-mutated tumors, osimertinib (80 mg once daily) is recommended for 3 years, due to its ability to target the EGFR mutation and reduce the risk of recurrence 1.
• Comprehensive molecular testing should be performed to confirm the specific mutation type, as different EGFR mutations or ALK rearrangements may influence treatment selection.
• Regular monitoring for treatment-related adverse effects is essential, including liver function tests every 2-4 weeks initially, then monthly, and cardiac monitoring for ALK inhibitors.
• Patients should also undergo surveillance imaging every 3-6 months during treatment to assess for recurrence. The most recent guidelines from the Journal of Clinical Oncology 1 support the use of alectinib, lorlatinib, and osimertinib as adjuvant targeted therapies for ALK-positive and EGFR-mutated adenocarcinoma of the lung, and recommend simultaneous testing of PD-L1 and molecular testing of EGFR to select the appropriate therapy 1.

From the FDA Drug Label

ALECENSA is indicated as adjuvant treatment in adult patients following tumor resection of anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC) (tumors ≥ 4 cm or node positive), as detected by an FDA-approved test [see Dosage & Administration (2.1)]. The recommended dosage information for ALECENSA is provided in Table 1. Table 1: ALECENSA Recommended Dosage and Duration of Treatment Indication | Recommended Dosage of ALECENSA | Duration Adjuvant treatment of resected NSCLC | 600 mg orally twice daily with food | For a total of 2 years or until disease recurrence or unacceptable toxicity Metastatic NSCLC | Until disease progression or unacceptable toxicity

The recommended treatment for patients with ALK-positive adenocarcinoma of the lung with a positive 10R lymph node is alectinib (ALECENSA) 600 mg orally twice daily with food for a total of 2 years or until disease recurrence or unacceptable toxicity 2. However, for EGFR-mutated adenocarcinoma of the lung, the provided drug labels do not directly support the answer. No conclusion can be drawn for EGFR-mutated adenocarcinoma of the lung.

From the Research

Treatment Options for ALK-positive or EGFR-mutated Adenocarcinoma of the Lung

The treatment for patients with ALK (Anaplastic Lymphoma Kinase)-positive or EGFR (Epidermal Growth Factor Receptor)-mutated adenocarcinoma of the lung with a positive 10R lymph node involves several considerations, including the use of targeted therapies and chemotherapy.

• Targeted Therapies: For patients with ALK-positive adenocarcinoma, alectinib and brigatinib have shown superior efficacy compared to crizotinib, with improved progression-free survival (PFS) and central nervous system penetration 3, 4.
• EGFR-mutated Adenocarcinoma: Osimertinib has become a standard treatment for EGFR-mutated non-small cell lung cancer (NSCLC), offering improved PFS and central nervous system penetrance compared to first- and second-generation EGFR TKIs 5, 4.
• Combination Therapies: The use of combination therapies, including chemotherapy and targeted agents, has shown promise in certain cases. For example, the combination of osimertinib and crizotinib, followed by chemotherapy plus bevacizumab, achieved a stable disease in a patient with EGFR mutation and ALK rearrangement 5.
• Immunotherapy and Angiogenesis Inhibitors: Immunotherapy, such as checkpoint inhibitors, and angiogenesis inhibitors, like bevacizumab, may also play a role in the treatment of lung adenocarcinoma, particularly in cases with PD-L1 overexpression or ALK/EGFR co-alterations 6, 7, 4.

Considerations for Treatment

When determining the best course of treatment, several factors should be considered, including:

• The presence of specific molecular alterations, such as ALK rearrangements or EGFR mutations
• The patient's performance status and overall health
• The extent of disease, including the presence of lymph node metastases
• The potential for resistance to targeted therapies and the need for combination or sequential treatments 5, 3, 4