LUNG CANCER BRONHOPULMONAR

Prezentare de caz

• 38-ani , femeie

• Maritata, 1 copil de 1 an

• Nefumatoare

• Fara comorbiditati

• Prezentare: tremor al bratului dr.

• Fara simptome respiratorii• Fara semne generale: CP = ct, IP = 0

• CT cerebral• Leziune parietala stg (2

cm diametru)

• CT pulmonar + abdomen sup.

• tumora in LSS : cT1N0

• Diagnostic: cc.pulmonar statiul IV

• cT1N0M1

Femeie, 38 ani, nefumatoare, IP = 0 adenocarcinom pulmonar cu M+ cerebrala unica, simptomatica : T1 N0 M1

Care e tratamentul cel mai potrivit?

• CH ?

• RT (stereotactica, RTE) ?

• CH: M+ rezecabila – ian 2006.

• HP: M+ de adenocarcinom, cu origine probabila in plaman

• M1 (6th TNM classification)

• M1b (7th TNM classification)

Stadializarea cu acuratete – evaluarea mediastinului e importanta pt. prognostic si tratament optimal Cum stadializam?

• PET-CT ?• CT ?

• PET and PET CT sunt superioare in evaluarea N mediastinal vs CT.

• References:De Leyn P et al. Eur J Cardio-thoracic Surg 2007, 32: 1-8

Ce tratament ar fi optimal daca boala la nivel toracic este rezecabila?

• CH ?• Fara CH?

• Lobectomia lobului sup. Dr. + limfadenectomie mediastinala

• Tu. Primara (2.8 cm) + lez. satelita lesion (0.7 cm) in acelasi lob

• pN+: – 3/7 iN intrapulmonarintrapulmonal nodes– 1/2 N para-aortici

• pT4pN2  (6th TNM classification)

Diagnostic final: Adenocarcinom pulmonar std. IV, la o femeie de 38 de ani, nefumatoare : pT1pN2M1.

Ce determinari moleculare ar fi utile? • p53 ?• EGFR mutatii ?• ERCC1 ?

• Mutatiile activatoare EGFR sunt frecvente la paciente femei, nefumatoare, asiatice

References:

Rosell R, NEJM, 2009

Mok T, NEJM 2009

Ce tratament facem mai departe?

• PCT ?

• TKI-s ?

• RTE cerebrala ?

• Nu are evidenta bolii: RC post-opPCT “adj”. mart. – iun. 2006

• Cisplatin + gemcitabina, 4 cicluri

+

• RTE cerebral – iun. 2006

• 30 Gy

• Important pt. decizia terapeutica: pacientii oligometastatici pot beneficia de CH (cazuri selectate: rezecabile, metastaze.

• PCT pt. tratamentul bolii microscopice, desi nu exista dovezi + PCT vs - PCT pt. situatiile tu. Cu M+ rezecabile.

• Follow-up: CT scan torace + abdomen sup. / 7. ian 2008 : resuta unica hil stg : 2,5 cm, fara alte leziuni

• Resuta locala: RTE / torace: 70 GY• In 28 Mai 2008, CT : RC

• In 23 Septembrie 2008, MRI: leziune cerebrala parietala stg. asimptomatica (1.2 cm). CT scan / torace, abdomen sup. = normal

• RT stereotactica - γ-knife/ lez. Cerebrala/ 7 Oct. 2008.

 • MRI cerebral / 7. ian. 2009: lez. parietala stg in

RP• Insuf. Resp.

• CT scans / torace si abdomen sup.: efuzie pleurala

Mai faceti alte investigatii? • DA ?• NU ?

• Determinarea status m EGFR • M EGFR + / exon 19

Which treatment would you now recommend?

A Nici unulB Dublet de platinaC Dublet de platina plus bevacizumab

• La pacientii m EGFR + , TKIs (Gefitinib sau Erlotinib) sunt sup. Vs PCT privind SFP si QL  

• Gefitinib aprobat pt. ptc. cu adenocarcinom cu mutatii activatoare EGFR independent de linia de tratament, status fumator/nefumator

Reference: • IPASS: Gefitinib vs. carboplatin/paclitaxel, Mok T et al. NEJM 361, 947-957, 2009• First Signal: Gefitinib vs. carboplatin/paclitaxel, Lee et al. WCLC 2009• Patients with EGFR-activating mutations, • WJTOG 3405: Gefitinib vs. cisplatin/docetaxel Mitsudomi T et al. Lancet Oncology 2010,

11, 121• NEJ 002: Gefitinib vs. carboplatin/paclitaxel Maemondo M et al. NEJM 2010, 11, 121• OPTIMAL: Erlotinib vs. carboplatin/gemcitabine Zhou C et al. ESMO 2010

• Patients previously treated with chemotherapyINTEREST studyLUX-Lung 2 study

• RP/ CT scan

• In Mai 2011, pacientul este in continuare in tratament cu Gefitinib.

• Pacienta este actual asimptomatica

Treatment: Issues in 2011

• EGFR mutation analysis at initial diagnosis

• Role of surgery in patients with EGFR-activating mutations – Brain– Primary tumor

• Firstline therapy – Chemotherapy (pemetrexed-based?)– Chemotherapy plus bevacizumab