The impact of preoperative imaging strategies in EGFR-mutant non-small cell lung cancer: a multicenter retrospective review.

Background: The ADAURA trial demonstrated an overall survival benefit with adjuvant osimertinib in epidermal growth factor receptor-mutant (EGFR-mut) non-small cell lung cancer (NSCLC). As only 50% of patients underwent a preoperative brain MRI scan and PET-CT rates were not reported, concerns were raised that suboptimal staging could have led to the inclusion of patients with metastatic disease. There is, however, limited data on the real-world rates and impact of preoperative PET-CT and brain MRIs in patients with EGFR-mut NSCLC. We sought to characterize preoperative imaging rates and their impact on staging. Patients and Methods: We retrospectively analyzed patients with EGFR-mut NSCLC who were evaluated for surgery at 3 academic New York hospitals from 2016-2021. Results: Between 2016 and 2021,109 patients with EGFR-mut NSCLC underwent preoperative evaluation. Of these patients, 107 underwent a PET-CT and 15 (14%) were found to have stage IV disease. Sites of metastatic disease were bone (11), pleura (2), liver (1), and intrapulmonary (1). Thirty-nine patients had stage II or III disease; of those, 23 underwent a brain MRI, which revealed brain metastases in 3 patients. In total, the use of PET-CT and brain MRIs for patients evaluated for surgery upstaged 17% (18/109) of patients to metastatic disease and resulted in 83% (90/109) of patients undergoing surgery. Conclusions: The use of preoperative PET-CT and brain MRIs led to the detection of metastatic disease in 17% of patients with EGFR-mut NSCLC. These findings underscore the critical role of comprehensive preoperative imaging for clinical practice and clinical trials.