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Non-small cell lung cancer — early and locally advanced stages
Stages I–II are operated on (or treated with SBRT when surgery is not possible), unresectable stage III gets concurrent chemoradiation followed by immunotherapy, and every decision starts with the mediastinum and the EGFR and ALK status.
Why it matters in the exam
This is one of the most frequent topics in the oncology exam, in both the radiation and the systemic parts. The typical stem gives a patient with a lung mass, its size, the nodal status and the performance status (ECOG) and asks for the next step: surgery, SBRT, chemoradiation, neoadjuvant or adjuvant therapy. The decision almost always rests on three questions: are the mediastinal nodes involved, is the patient fit for surgery, and is there an actionable mutation. Details on radiation pneumonitis, the Pancoast tumour and landmark trials such as PACIFIC and ADAURA also appear. Remember that an older patient or one with severe COPD is not always a surgical candidate, and then SBRT gives very high local control in a small tumour.
Key points
- In stage I lobectomy is standard, and SBRT is the alternative for patients unfit for surgery.
- Invasive mediastinal staging is needed for suspicious nodes, a centrally placed tumour or one larger than 3 cm.
- In resectable stages II–IIIA systemic therapy is added — neoadjuvant or adjuvant — after EGFR, ALK and PD-L1 testing.
- In unresectable stage III: concurrent chemoradiation 60 Gy in 30 fractions followed by durvalumab for one year.
- EGFR and ALK also change adjuvant therapy: osimertinib for 3 years or alectinib for 2 years.
Summary table
| Stage | Main treatment | Addition | Exam note |
|---|---|---|---|
| I (node-negative) | Lobectomy with nodal sampling | SBRT for patients unfit for surgery | Peripheral tumour up to 2 cm — segmentectomy is acceptable |
| II to IIIA resectable | Surgery | Neoadjuvant chemo-immunotherapy or adjuvant platinum-based chemotherapy | EGFR-positive — adjuvant osimertinib for 3 years; ALK-positive — adjuvant alectinib for 2 years |
| III unresectable | Concurrent chemoradiation, 60 Gy in 30 fractions | Durvalumab for one year (PACIFIC trial) | EGFR-positive — osimertinib after chemoradiation instead of durvalumab |
| Pancoast tumour | Neoadjuvant chemoradiation then surgery | Assess brachial plexus and vertebral involvement | Horner syndrome and shoulder and arm pain |
| Patient unfit for chemotherapy | Radiation alone or hypofractionated radiation | Supportive care | Decision by ECOG and lung function |
| After surgery with unexpected N2 | Adjuvant systemic therapy | Postoperative radiation is not routine (Lung ART trial) | Radiation reserved for positive margins or residual tumour |
Free exam questions
בת 54 עברה כריתת אונה עליונה של ריאה שמאל. בתשובה הפתולוגית adenocarcinoma חיובית ל- TTF1 בגודל 3 ?ס"מ עם בלוטה אחת חיובית בפרנכימת הריאה. מה הטיפול עבורה (the question as examined, in Hebrew)
- א. מעקב בלבד
- ב. טיפול מניעתי בכימותרפיה, קרינה ולאחר מכן durvalumab
- ג. קרינה פוסט ניתוחית לשער הריאה
- ד. ארבעה קורסים של cisplatin+vinoralbine
בן 65 אובחן כסובל מ Non Small Cell Lung Cancer Adenocarcinoma ב קוטר 6 ס"מ באונה ימנית עליונה ב pet CT .בלוטה אחת קולטת בשער הריאה הימני, ללא ממצאים נוספים, מה ה גישה ? (the question as examined, in Hebrew)
- א. לובקטומיה של הגידול וכימותרפיה אדג'ובנטית על בסיס cisplatin
- ב. כימותרפיה וקרינה לסך של 45 גריי, ולאחר מכן durvalumab לשנה
- ג. ביצוע אנליזה מולקולרית מקיפה על הגידול וטיפול לפי סטטוס EGFR ו- ALK
- ד. בדיקה פולשנית לדגימת הבלוטות שלא קולטות FDG במיצר
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Oncology, Medical licensing exam (IMLE), Internal medicine, General surgery.
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer, 2026 — Principles of surgical therapy and radiation therapy
- ESMO Clinical Practice Guideline: Early and locally advanced NSCLC, 2017, updated 2024 — Diagnosis, treatment and follow-up
- DeVita, Hellman and Rosenberg's Cancer: Principles and Practice of Oncology, 12th ed. (2023) — Non-small cell lung cancer
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.