Radiothérapie et immunothérapie : avant, pendant ou après ?

Abstract

Locally-advanced non-small cell lung cancer (NSCLC) stage III patients, represent one quarter of the whole NSCLC patients at diagnosis. Historical studies and the LACE meta-analysis showed the superiority of concurrent chemo-radiotherapy over sequential radiotherapy with a survival benefit of 5% at five years. The main advance in recent years has been the PACIFIC trial, which compared durvalumab with placebo for one year, after induction chemo-radiotherapy, in non-resectable stage III patients. Maintenance durvalumab survival advantage was obvious, with a median survival of 47.5 months in the experimental arm, compared to 29.1 months in the placebo arm (HR = 0.68), with a median follow-up exceeding 5 years, such survival benefit being absent in patients whose tumor had an oncogenic addictive mutation. Durvalumab association with other immune checkpoint inhibitors (anti CD73, anti NKG2A) appears promising in phase 2 trials, in such maintenance indication, phase 3 results being awaited. Feasibility of chemo-immunotherapy association with concurrent radiotherapy is currently assessed in many preliminary studies, with a specific focus on pulmonary safety. Neo-adjuvant immunotherapy before radio-chemotherapy is less extensively studied, with only fragmentary available data. The improvement or immunotherapy strategies, in association with chemo-radiotherapy in stage III non-resectable NSCLC patients, is thus possible in close future, even though PACIFIC trail results will be difficult to outperform.1877-1203/© 2022 SPLF. Published by Elsevier Masson SAS. All rights reserved.