Clinical challenges in the management of stage III EGFRmutated non-small cell lung cancer: integrating surgery and adjuvant therapy in the post-ADAURA era

Introduction: Locally advanced EGFR-mutated non-small cell lung cancer (NSCLC) poses therapeutic challenges regarding the integration of neoadjuvant chemotherapy, surgery, and adjuvant targeted therapy. Case presentation: A 73-year-old woman was diagnosed with lung adenocarcinoma staged as cT3–T4 N0–1 M0, stage IIIA (AJCC 8th edition), PD-L1 negative, harboring an EGFR exon 19 deletion. Following multidisciplinary thoracic tumor board discussion, neoadjuvant chemotherapy was administered with the aim of downstaging due to pericardial invasion and suspected diaphragmatic involvement. Between March and May 2023, she received four cycles of carboplatin (AUC 4) and paclitaxel (135 mg/m²), achieving stable disease as the best radiological response. In July 2023, an extended left lower lobectomy with en bloc resection of the diaphragm and pericardium was performed. Pathological examination revealed ypT4N0 disease with no nodal involvement (0/13 lymph nodes). After confirmation of the EGFR exon 19 deletion, adjuvant osimertinib 80 mg daily was initiated. Discussion: This case highlights the integration of neoadjuvant chemotherapy, complex surgery, and adjuvant targeted therapy in locally advanced EGFR-mutated NSCLC. Conclusion: The case underscores the importance of a multidisciplinary and sequential treatment approach in stage III EGFR-mutated NSCLC in the post-ADAURA era.