The development and approval of three generations of ALK tyrosine kinase inhibitors (TKIs) since the identification of anaplastic lymphoma kinase fusions (ALK+) in NSCLC has led to improved survival especially with lorlatinib, the only third-generation ALK TKI in the metastatic incurable stage. The establishment of 3 years of adjuvant EGFR TKI in resected stage IB-IIIA EGFR+ NSCLC has led to improvement in overall survival (OS) when compared to placebo. Logically, the use of adjuvant ALK TKI in resected early-stage ALK+ NSCLC has been investigated. But instead of three years of adjuvant TKI, in line with EGFR+ and RET+ NSCLC, the use of ALK TKI was investigated for only 2 years in both ALINA and ELEVATE trials. Unsurprisingly, alectinib (ALINA trial) and ensartinib (ELEVATE trial), respectively, has led to improved disease-free survival (DFS) so far with OS follow up on-going. Nonetheless, this is a disease that requires constant tumor suppression to prevent or delay CNS metastasis, as exemplified by the CNS data from the 7-year CROWN update. In addition, to reviewing the results of ALINA and ELEVATE, we propose two alternate novel clinical designs to build upon the 2-years of adjuvant 2G ALK TKIs.

Pneumomediastinum from tracheal perforations due to primary repair breakdown can occur as a complication of thymic cancer surgery. Immunotherapy may be a viable adjuvant treatment for thymic carcinoma patients with tracheal perforations.

Lung cancer (LC) screening with low-dose computed tomography (LDCT) reduces mortality through early-stage detection, yet evidence on long-term effectiveness and adherence remains limited. This study reports nearly 10-year outcomes from the prospective BioMILD trial, which enrolled 4,119 heavy smokers undergoing risk-adapted screening with LDCT. Participants were stratified by baseline LDCT results into LDCT + and LDCT - groups, and the latter were sent to triennial intervals. Over a median follow-up of 9.4 years (38,676 person-years), 248 LCs were diagnosed (6.0 %), with significantly higher incidence in the LDCT + group (21.8 % vs 3.0 %, p < 0.0001). Early-stage disease predominated across all four screening intervals (0-2, 3-5, 6-9, and ≥ 9 years), with stage I proportions consistently around or above 50 %. Ten-year all-cause and LC mortality were significantly higher in the LDCT + group (14 % and 5 %) compared to the LDCT - group (6 % and 1 %) (p < 0.0001). Screening adherence remained high at 3-5 years (92 %) and acceptable beyond 9 years (58 %), with no group differences. Baseline LDCT effectively stratified long-term risk, with over seven-fold higher LC incidence in LDCT + participants. However, LC cases continued to emerge in the LDCT - group, indicating that a negative baseline LDCT does not eliminate long-term risk. Despite differing risk profiles, screening maintained a consistent ability to detect early-stage LC across groups. In conclusion, long-term risk-adapted LDCT screening in the BioMILD trial sustained early-stage LC detection and acceptable adherence over nearly a decade, supporting continued surveillance even among initially low-risk individuals.

Accurate mediastinal staging of suspected lung cancer is critical for guiding treatment and determining prognosis. While computed tomography (CT) and positron emission tomography (PET) are integral to initial staging, both modalities have limitations for detecting nodal metastases. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides a minimally invasive option for obtaining tissue confirmation. This study evaluates the impact of adding EBUS-TBNA at the time of lung tumor biopsy on mediastinal staging accuracy. We conducted a retrospective study of patients who underwent shape-sensing robotic-assisted bronchoscopy (ssRAB) with concurrent EBUS-TBNA between June 2020 and December 2025. Preprocedural CT and PET findings were compared with EBUS-TBNA cytopathology to assess their diagnostic performance and to evaluate stage migration in patients with primary pulmonary malignancies. A total of 1,234 patients underwent ssRAB with EBUS-TBNA, of whom 123 (10.0 %) had malignant lymph nodes on cytopathology. Among these, 23 patients (18.7 %) had no suspicious lymphadenopathy on preprocedural CT and/or PET imaging. The sensitivity of CT and PET for detecting malignancy at specific lymph node stations was 44.5 % and 68.5 %, respectively. In the clinical-to-EBUS staging analysis, 66 (74.2 %) demonstrated no major stage change, while 23 (25.9 %) experienced stage migration. Concurrent EBUS-TBNA identified occult nodal involvement and resulted in stage migration. These findings underscore the critical role of EBUS-TBNA in identifying clinically occult nodal disease and optimizing lung cancer treatment.