Abstract
Metastatic non-small cell lung cancer (NSCLC) has generally poor prognosis. Primary choice of treatment originates from the NSCLC subtype (squamous, nonsquamous), PD-L1 expression result and in nonsquamous histology from the mutation status EGFR, ALK, event.
ROS1, BRAF (ROS1 and BRAF are tested in case in which targeted treatment is available). The use of immune checkpoint inhibitors (ICIs) in first line alone or in combination with chemotherapy is the standard practice.
In the most ICIs there is the condition to exclude EGFR and ALK in nonsquamous histology. If the PD-L1 expression is 50% or more, there is the recommendation to use pembrolizumab in monotherapy.
In case of lower expression, even less than 1%, combination chemotherapy and immunotherapy is the choice. In patients with the high mutation burden (TMB) more than 10 mutation per megabase the combination of nivolumab plus ipilimumab is recommended.
The given choice of treatment is strictly individualized, on the base of decision of tumor board, ideally with the presence of patient. The treatment must be settled after the benefit-risk assessment.