ESMO E-Learning: Diagnostic Work Up in NSCLC and the Importance of Optimal Tissue Management in the Era of Precision Medicine

This E-Learning module provides a significant update of the previous ESMO module on rapidly evolving biomarkers landscape in patients with metastatic non-small cell lung cancer (NSCLC). The authors strongly advocate that all patients with unresectable NSCLC require biomarkers screening at diagnosis with turnaround time for providing results within 5–10 days to select first-line treatment. They also strongly advocate for the adoption of next-generation sequencing (NGS) into routine practice.

In the outline of this module, the authors elaborate precision medicine in patients with advanced NSCLC, including molecular classification and driver oncogenes in lung adenocarcinoma by different ethnicities. This part is followed by the elaboration of recommendations for biomarker testing from the latest ESMO Clinical Practice Guidelines in metastatic NSCLC.

The part of the module on optimal diagnostic work-up of lung cancer, elaborates issues of sample journey for testing, morphology and histology in terms of immunohistochemical markers and cytology for molecular diagnostics, type of samples for genomic evaluation, input requirements for biomarker testing and quality control for biomarker testing, as well as the strategy to maximise tissue for molecular testing.

The next chapter details the guidelines recommendations for predictive biomarkers testing, in particular testing of PD-L1, EGFR, ALK, ROS1, BRAF, NTRK, and the evolving landscape of other actionable predictive biomarkers, such as RET, MET, KRAS, HER2, and EGFRins20.

The authors underline that adoption of NGS into routine practice is more efficient and facilitates the comprehensive characterisation of predictive and emerging drivers, co-occurring genomic events, as well genomic alterations linked to resistance. They provide an overview of ESCAT levels for the alterations in patients with metastatic NSCLC and the recommendations from the ESMO Precision Medicine Working Group for NGS use in these patients.

The authors conclude that, in the era of precision cancer therapeutics, all professionals involved in the diagnosis and management of patients with lung cancer should develop their own multidisciplinary tissue management strategy to optimise tissue processing and facilitate reflex testing.