驅(qū)動(dòng)基因陽(yáng)性和陰性晚期肺癌治療2025

聯(lián)合相應(yīng)靶向藥物，無(wú)明確靶點(diǎn)時(shí)：推薦化療士免疫治療。表1聯(lián)合相應(yīng)靶向藥物，無(wú)明確靶點(diǎn)時(shí)：推薦化療士免疫治療。表1.驅(qū)動(dòng)基因陽(yáng)性晚期NSCLC治療：ASCO指南一線推薦ClinicalQuestionfirst-lineoptionsbasedonthealterations?79L858RCliniciansshouldofferosimertinib1.1.1.CliniciansmayofferWeakdoubletvantamabpluslazertinibQualifyingrecommendationpatientstargetthisguideline,subgroupanalysesindicatepatientsselecthigh-riskfeaturesderive1.1.1.Thefullmanuscriptpresentsthatmaybebasedtheevidencereviewedinaddition,thistreatmentpatientsweretreatedadjuvantTKIs.Foractivatingalterations,L861QS768I),mayofferafatinib1.2.1.orosimertinibWeak1.2.2.standardfollowingtheWeaknon-driverguidelineQualifyingRecommendationsexcludesexoninsertionT790MForanyactivating-gardlessPD-L1expression(20insertions),single-agentimmuneinhibitorsofferedfirst-lineinsertionsofferStrongamivantamabIfamivantamabisavailable,-offerstandardALKshouldalectiniborbriga-HighbrigatinibrlorlatinibarenotHighStrongcliniciansofferceritinibR0S1maycrizotinib.entrectinib,repotrectinibcrizotinib,entrectinib,orWeaknotavailabletolerated,cliniciansmayofferceritinibor76^1.10.maydabrafenibStrongencorafenibandIforencor-binimetinibnotavailable,mayofferfirst-linethealterationmutation1.12.mayoffercapmatinibortepotinib1.13.IfcapmatinibStrongfirst-linefollowingthealterationfollowingpage)DriverAlterationRecommendationEvidenceQualityStrengthofRecommendationRETrearrangement1.14.CliniciansshouldofferselpercatinibHighStrong1.15.Ifselpercatinibisnotavailable,cliniciansModerateStrongmayofferpralsettmb1.16.IfselpercatiniborpralsetinibarenotLowWeakavailable,cliniciansmayofferstandardtherapyfollowingthenon-driveralterationguidelineNTRKrearrangement1.17.CliniciansmayofferentrectiniborLowStronglarotrectinib1.18.IfentrectiniborlarotrectinibarenotLowWeakavailable,cliniciansmayofferstandardtherapyfollowingthenorwiriveralterationguideline1.19.ForpatientswithapoorPS,TKImaybeofferedbasedondrugaccessandtoxicityLowWeakprofile1.20.Biomarkertestingwithatissueand/orblood-basedbroadmulti-genepanelandanHighStrongIHCassayforPD-L1andHER2shouldbeuniversallyaccessibleforallpatientsdiagnosedwithNSCLCQualifyingStatement:Combinationofbloodandtissuetestingmaymaximizechanceofdetectingmolecularalterations.Tissuetestinghasadvantageofhistologicassessmentandshouldbeattemptedwhenfeasible,andthefalsenegativerateofliquidbiopsyshouldbeconsidered.PD-L1IHCaloneshouldnotbeusedtoguidetreatmentdecisionsTreatmentdecisionsbasedonHER2overexpressionarerestrictedtosecondlineandbeyond1.21.PatientswithadvancedlungcancershouldbereferredtointerdisciplinarypalliativeHighStrongcareteams(consultation)thatprovideoutpatientandinpatientcareearlyinthecourseofdisease,alongsideactivetreatmentoftheircancer表2.表2.驅(qū)動(dòng)基因陽(yáng)性晚期NSCLC治療：ASCO指南二線推薦ClinicalQuestion2Whatarethemosteffectiveseconddineandsubsequenttreatmentoptionsforpatientsbasedonthedriveralterations9Duetodevelopmentofpotentiallytargetableresistancemechanisms,everyeffortshouldbemadetoassessforpresenceofnewmutationbytissueand/orbloodNGStestingtoinfonnsubsequenttreatment.Ifpatientshavereceivedalltargetedoptions,orifnotargetedoptionsareavailable,cliniciansmayofferstandardtherapyfollowingthenon-driveralterationEGFRExon19deletion,Exon21L858Rsubstitution2.1ForpatientsthatdevelopEGFRT790MHighStrongresistancealterationsintumorafterfirst-orsecond-generationEGFRTKIs,clini-ciansshouldofferosimertmib22.ForpatientswhosediseasehasproModerateStronggressedonosimertiniborotherEGFRTKIswithoutemergentT790Morothertargetablealterations,cliniciansmayof-ferplatinum-basedchemotherapywithorwithoutamivantamabQualifyingStatement:ForpatientswhosediseasehasprogressedonEGFRTKIsandnottreatedwithamivantamabandchemotherapy,chemotherapyalone±anti-VEGF-targetingtherapycombinationsmaybeconsideredforthosewithadenocarcinomahistologyandwhereanti-VEGFtherapyisconsideredsafe2.21ForpatientswhohaveprogressiveModerateStrongdiseaseonosimertinib(orother3rd-generationTKI),cliniciansmayofferplatinum-basedchemotherapywithorwithoutamivantamab2.2.2.ForpatientswhohaveprogressiveHighStrongdiseaseonEGFRTKI,anti-PD-(L)1agentswithorwithoutplatinumche-motherapyarenotrecommendedQualifyingStatement:MultiplephaseIIItrialshaveshownnobenefittoadditionofPD-1toplatinumchemotherapy;however,theroleofadditionalimmunecombinations,includingVEGF,arebeingexploredintrials.Exon20insertions2.3.Forpatientswithanexon20insertionLowStrongalterationwhohavereceivedpriortreat-mentwithplatinumchemotherapy,clnniciansmayoffertreatmentwithamrvantamab(continuedonfollowingpage)DriverDriverEvidenceQualityofALK2.4.ForStrongcliniciansbrigatinib.ceritinibmayofferlorlatinib2.5.ForpatientshavereceivedLowinhibitorsalectinibbrigatinib,cliniciansmayofferR0S12.6.Forpatientshavereceivedentrectinib,lorlatinib,mayrepotrectinibForhaveLowStronginhibitors,clinicianschemotherapyfollowingnon-driver2.8.ForpatientswhohavereceivedStrongtherapy,mayofferdabrafenibencorafenibbinimetinib2.9.ForpatientshaveLowStrongortargetedtherapy,cliniciansshouldstandardfirst-linefol-non-driverguidelineForalterationsLowStrongalterations,offerstandardtherapyalterationMET14mutation2.11.ForpatientswhohavenotreceivedMET-Lowtargetedtherapy,clinicianscap-matmibtepotinibForLowMET-targetedcliniciansofferstandardguidelinerearrangementForwhohavereceivedaclinicianspercatinibpralsetinibIfpralsetinibisavailable,mayofferthealterationrearrangement2.15.ForwhohavereceivedanLowStrongcliniciansofferentrectinibIfentrectiniborlarotrectinibisLowavailable,maystandardnon-driveralteration2.17.offerLowtrastuzumabKRAS2.18.sotorasibofferLowadagrasibQualifyingthatadagrasibandareapprovedwhohaveprior-motherapy