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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-op
PCT 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 - -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 unul
B Dublet de platina
C 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 chemotherapy
INTEREST study
LUX-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