Documente Academic
Documente Profesional
Documente Cultură
epidemiologie
istorie natural
simptomatologie,
diagnostic
evoluie
indicaie terapeutic
EPIDEMIOLOGIE
Cancerul bronho-pulmonar (CBP) reprezint cea mai important
neoplazie uman n termenii incidenei i mortalitii.Incidena CBP n
Uniunea European este de 52.5/ 100.000 locuitori/an, iar mortalitatea de
48.7/100.000 locuitori/an (375.000 cazuri noi i 347.000 decese n 2000).
La sexul masculin incidena este de 82,5/100.000 brbai/an, i
mortalitatea de 77,0/100.000 brbai/an, iar la sexul feminin de
23,9/100.000 femei/an, i respectiv 22.3 cazuri/100.000 femei/an [1].
Aproximativ 90% din mortalitatea produs de CBP la brbai i 80% la
femei, este atribuit fumatului. n Europa, ratele de mortalitate sunt n
cretere accentuat la sexul feminin, datorit numrului din ce n ce mai
mare de femei fumtoare. Supravieuirea la 5 ani a crescut modest n
ultimii 25 ani, rmnnd de aproximativ 14% [2,3].
n Romania, n aceeai perioad, CBP nregistreaz o mortalitate de
59.29/100.000 locuitori/an la brbai i respectiv 12.4/100.000
locuitori/an la femei. n cadrul mortalitii specifice prin cancer, CBP
ocup locul I la brbai i locul III la femei.
CBP prezint dou tipuri majore clinice, histologice i terapeutice:
cancerele bronho-pulmonare non-microcelulare (non-small cell,
HISTOLOGIE
Cancerul bronho-pulmonar non-microcelular (CBPNM, 80-85% dintre
carcinoamele pulmonare) reprezint un ansamblu heterogen format din
cel puin 3 tipuri histologice distincte, incluznd carcinomul scuamos
(epidermoid), adenocarcinomul i carcinomul cu celule mari
(nedifereniat). Aceste tipuri histologice sunt clasificate mpreun
deoarece prezint aspecte biologice, clinice i terapeutice similare.
TABEL 1. Clasificarea OMS a cancerelor non-microcelulare [5]
I. Carcinom scuamocelular (50%)
epidermoid
cu celule fusiforme
II. Adenocarcinom (15%)
acinar
papilar
mucinos
bronhiolo-alveolar
III. Cu celule mari (anaplazic) (15%)
cu celule mari
cu celule mici
cu celule clare
IV. Adenoscuamos
DIAGNOSTIC
Examen clinic
radiografie toracic
examen CT toracic i abdominal superior
examen neurologic i examene imagistice cerebrale (CT, IRM)
doar n cazuri simptomatice
scintigrama osoas
tumor de orice dimensiuni care invadeaz direct oricare din urmtoarele: mediastinul,
inima, marile vase, traheea, esofagul, corpii vertebrali, carina;
sau noduli tumorali separai n lobi pulmonari controlateral de tumora primar.
sau tumora cu pleurezie malign**
N (adenopatiile loco-regionale)
Nx
ganglionii limfatici regionali nu pot fi evaluai
No
fr metastaze n ganglionii limfatici regionali
N1
metastaze n ganglionii peribronici ipsilaterali i/sau hilari ipsilaterali i ganglionii
intrapulmonari inclusiv invazia prin extensie direct a tumorii primare
N2
metastaze n ganglionii mediastinali ipsilaterali i/sau subcarinali
N3
metastaze n ganglionii mediastinali controlaterali, hilari controlaterali, ipsilaterali sau
controlaterali scalenici, sau supraclaviculari
M (metastazele la distan)
Mx
Metastazele la distan nu pot fi evaluate
Mo
Metastaze la distan absente
M1
Metastaze la distan prezente
M1a noduli tumorali separai n lob controlateral: tumoare cu noduli pleurali sau
pleurezie malign sau pericardit.
M1b
metastaze la distan
pTNM Clasificarea patologic
Categoriile pT, pN i pM corespund categoriilor T, N i M clinice.
pNo Examinarea histologic dup limfadenectomie va include 6 ganglioni hilari i mediastinali
Gruparea pe stadii
Cancer ocult
Tx
Stadiul 0
Tis
Stadiul IA
T1a,b
Stadiul IB
T2a
Stadiul IIA
T2b
No
No
No
No
N1
Mo
Mo
Mo
Mo
Mo
Stadiul IIB
Stadiul IIIA
Stadiul IIIB
Stadiul IV
T1a,b
N1
T2a
N1
T2b
N1
T3
No
TT1a,b N2
T3
N1, N2
T4
N2
Mo
Mo
Mo
Mo
Mo
Mo
Mo
T4
Orice T
Orice T
Mo
Mo
M1
N2
N3
Orice N
PROGNOSTIC
Factorii de prognostic favorabil n stadiile iniiale (I, II i III rezecabile)
mrimea tumorii
prezena sau absena metastazelor n ganglionii regionali
vrsta > 60 ani
sexul masculin
posibilitatea practicrii unei rezecii radicale (pneumectomie,
lobectomie, segmentectomie)
PRINCIPII DE TRATAMENT
Tratamentul loco-regional: Chirurgia
Gemcitabin
Paclitaxel
Carboplatin
Ifosfamid
Vindesin
Categoria
Generaia III
Generaiile I i II (clasice)
Terapia standard actual a CBPNM avansate trebuie s fie o asociaie de 2 citostatice, iar
selecia acestora trebuie s fie bazat pe toxicitate, cost, disponibilitate i experien.
Asocierea cisplatin (DT 400 mg/m) i vinorelbin pare cea mai activ
n adjuvan.
Chimioterapia de ntreinere (meninere) nu confer un avantaj de
supravieuire.
TABEL 3. Protocoale de chimioterapie recomandate n CBPNM [8]
Linia I de tratament
PG / CG
Cisplatin
100 mg/m
Carboplatin
AUC 5
Gemcitabin
1000 mg/m
Se repet la fiecare 3-4 sptmni.
I.V.
I.V.
I.V.
ziua 1
ziua 1
zilele 1,8,(15)
I.V.
I.V. (perfuzie 10)
ziua 1
zilele 1,(8),(15)
sau
VLB + C-DDP
Cisplatin
80-120 mg/m
Vinorelbin
30 mg/m
Se repet la fiecare 3-4 sptmni.
RR i supravieuire crescute (35-51% vs. 14%, 9.3 luni vs. 7.2 luni) fa de vinorelbina singur
I.V.
I.V.
ziua 1
zilele 1,8
I.V.
I.V. (perfuzie 30)
ziua 1
ziua 1
10
PC
Paclitaxel
225 mg/m
Carboplatin
AUC 5-7
Se repet la fiecare 3 sptmni.
RR 27-63%, supravieuire median 9-13 luni
PP
Paclitaxel
135 mg/m
Cisplatin
75 mg/m
Se repet la fiecare 3 sptmni.
EP
Cisplatin
60-100 mg/m
Etoposid
120 mg/m
Se repet la fiecare 3-4 sptmni.
I.V.
I.V.
ziua 1
zilele 1-3
I.V.
I.V.
ziua 1
zilele 1-3
CE
Carboplatin
300 -375 mg/m
Etoposid
100-130 mg/m
Se repet la fiecare 3-4 sptmni.
RR 10-30%
PCis
Pemetrexed*
500 mg/m2
I.V.
Cisplatin
75 mg/m2
I.V.
Se repet la fiecare 3 sptmni, 6 cicluri.
DOC + C-DDP
Docetaxel
75 mg/m
Cisplatin
75 mg/m
I.V.
Se repet la fiecare 3 sptmni.
ziua 1
ziua 1
I.V.
ziua 1
ziua 1
zilele 1,8
Superioar fa de best suportive care n CBPNM stadiul IIIB i stadiul IV (supravieuire median 28 luni vs. 21
sptmni, amelioreaz calitatea vieii)
Gemcitabin monoterapie
Gemcitabin
1000-1250 mg/m I.V. (perfuzie 15)
Se repet la fiecare 3-4 sptmni.
zilele 1,8,(15)
Superioar fa de best suportive care n CBPNM stadiul IIIB i stadiul IV (RR 20%, ameliorarea simptomelor n
70% i a statusului de performan n 44% din cazuri, reducerea numrului de zile de spitalizare, scderea
necesitii de radioterapie la 49% vs. 79% din cazuri).
I.V.
11
ziua 1
RR 15%, supravieuire median 7.5 vs. 4.6 luni, supravieuire la 1 an 37% vs. 11% (comparativ cu placebo)
Pemetrexed monoterapie
Pemetrexed*
500 mg/m2
Se repet sptmnal.
P.O.
ziua 1
12
13
Tratamentul simptomatic
TERAPEUTIC
Evoluia
cu forme avansate de CBPNM netratate este
Trialuripacienilor
clinice
Tratament multimodal
predictibil,
cu o supravieuire median de 4 luni i o rat de
supravieuire
la 1 an de 10-15% [25].
STADIUL IIIB
Boala nerezecabil
CHT + RT
TABEL
Recomandrile
RT 5.
(pacieni
cu IK redus)NCCN de tratament
CHT (pacieni cu pleurezie malign)
Boala rezecabil
CHT + RT rezecie chirurgical extins
Trialuri clinice
Diferite tipuri de fracionare a RT
Radiosensibilizatori
Anticorpi monoclonali
STADIUL IV
Tratament multimodal
n CBPNM
RT paliativ
CHT pe baz de sruri de platin
Chirurgie CHT RT (tumori rezecabile, MTS cerebral unic)
Terapie laser endobronic brahiterapie (leziuni obstructive)
Trialuri clinice
Noi regimuri de CHT
14
Stadiile I i II
15
Stadiul III
Stadiul IIIA rezecabil
16
17
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20
Cancerul bronho-pulmonar cu celule mici (microcelular, small cell, CBPCM) se distinge net
din punct de vedere clinic, biologic i terapeutic fa de celelalte subtipuri histologice de CBP
[1].
EPIDEMIOLOGIE
CBPCM reprezint aproximativ 20-25% din toate formele de CBP, incidena bolii fiind n
scdere cu 2-5% din anii 80 (de la 17.4% n 1986 la 13,8% n 1998).
HISTOPATOLOGIE
The International Association for the Study of Lung Cancer (IASLC) a propus n 1988 o nou
clasificare patologic a CBPCM, considernd 3 categorii diferite; aceast clasificare
patologic a fost recunoscut i de ctre OMS:
forma pur cu celule mici (small cell, lymfocyte-like) peste 90% din cazuri
forma intermediar (cu celule mici i variante de celule mari) 4-6% din cazuri
forma combinat (carcinom cu celule mici asociat cu carcinom scuamos sau
adenocarcinom) 1-3% din cazuri
Subtipurile histologice de CBPCM nu prezint diferene clinice sau prognostice importante.
Tumorile carcinoide atipice i CBPCM cu difereniere neuroendocrin prezint caracteristici
genetice i o evoluie clinic distincte de celelalte forme de CBPCM [3].
DIAGNOSTIC
Majoritatea pacienilor cu CBPCM prezint o leziune pulmonar identificabil, dei n
aproximativ 4% din cazuri leziunea pot fi localizate n sedii extrapulmonare (cap i gt,
esofag, colon, col uterin i altele).
Semnele i simptomele frecvente n CBPCM sunt datorate:
tumorii primare i extensiei locale:
metastazelor la distan:
sindroamelor paraneoplazice:
Aproximativ 2/3 dintre pacieni prezint metastaze la distan la diagnostic. Sediile cele mai
frecvente sunt osul, ficatul, sistemul nervos central (SNC) i mduva osoas; un numr
semnificativ de metastaze se poate observa n organele endocrine. Din aceste motive,
examenele complete pentru stadializare trebuie s includ [2,10]:
anamnez detaliat i examinarea fizic complet
radiografie toracic, examen CT toraco-abdominal (mai ales dac se va propune RT)
21
22
PRINCIPII DE TRATAMENT
Tratamentul loco-regional: Chirurgia
Iradierea profilactic cranian (IPC) este indicat la pacienii cu remisiune complet (RC)
dup tratament n boala limitat de CBPCM (reduce riscul de apariie a metastazelor
cerebrale i amelioreaz supravieuirea)
Doza optim i timpul de administrare a IPC rmn incerte; mai frecvent doza total nu depete 30 Gy (fracii 2.5
Gy).
Efectul IPC la pacienii cu BE i la cei fr RC la chimioterapie este nc neclar [19].
Datorit indicelui crescut de proliferare, CBPCM este histotipul cel mai sensibil la CHT.
Numeroase citostatice s-au dovedit active n CBPCM (Tabel 5 i 6).
Chimioterapia (CHT) reprezint principala modalitate terapeutic n toate stadiile de CBPCM,
dar, dei adesea tumora este teoretic vindecabil prin CHT (rspuns favorabil n 80% din
cazuri), recidiva este foarte frecvent (mai puin de 10% din cazuri supravieuiesc dup 2 ani)
[2].
Un numr redus de pacieni rmn n remisiune complet la 3 ani de la debutul tratamentului
i pot fi considerai vindecai. n studiile recente, rata de vindecare este apreciat la 3% pentru
toate stadiile.
TABEL 6. Ageni chimioterapici activi n CBPCM
Citostatic
Ifosfamid
Teniposid
Etoposid
Carboplatin
Ciclofosfamid
Citostatic
Rate de rspuns (%)
Metotrexat
35
Doxorubicin
30
Hexametilmelamin
30
Vindesin
30
Cisplatin
15
23
Vincristin
35
Lomustin
15
______________________________________________________________________________
Mai multe asociaii chimioterapice au fost utilizate cu succes (Tabel 6), fr a exista, pn
recent, diferene semnificative ntre un protocol i altul. Cel mai frecvent utilizat protocol
este etoposid-cisplatin (EP), datorit eficienei i profilului su toxic favorabil. Asociaia
carboplatin-etoposid prezint o activitate probabil echivalent, dar este cu certitudine mai
bine tolerat (indice terapeutic mai bun).
Noi citostatice s-au impus recent n tratamentul CBPCM: taxanii, gemcitabina, vinorelbina
i derivaii de camptotecin (irinotecan i topotecan) [16].
Asocierea paclitaxel la protocolul standard EP nu a demonstrat un beneficiu de supravieuire dect ntr-un singur
studiu din cele 3 efectuate (avantaj de 1 lun, dar cu toxicitate secundar important) [24].
I.V.
I.V.
I.V.
I.V.
zilele 1-3
ziua 1
zilele 1-3
zilele 1-3
CE
Carboplatin
AUC 5-6
Etoposid
100 mg/m/zi
Se repet la fiecare 3 sptmni.
I.V.
I.V.
ziua 1
zilele 1-3
sau
IP
Irinotecan
60 mg/m2
Cisplatin
60 mg/m2
Se repet la fiecare 4 sptmni.
I.V.
I.V.
zilele 1,8,15
ziua 1
CAV
Ciclofosfamid
1000 mg/m
Doxorubicin
45 mg/m
Vincristin
1.4 mg/m (Dmax 2 mg/ciclu)
Se repet la fiecare 3 sptmni.
I.V.
I.V.
I.V.
ziua 1
ziua 1
ziua 1
CAV alternativ cu EP
Se repet cte un ciclu din fiecare protocol, alternativ, la 3 sptmni.
ACE (AIE)
Ciclofosfamid
750 mg/m
Ifosfamid
2000 mg/m
Doxorubicin
40-50 mg/m
Etoposid
100-120 mg/m
Se repet la fiecare 4 sptmni (4-6 cicluri).
I.V.
I.V. (perfuzie 30)
I.V.
I.V.
ziua 1
zilele 1-5
ziua 1
ziua 1-3
RR 70-80% (RC 40%), supravieuire median 14 luni (BL) i respectiv 9 luni (BE).
CAVE
Ciclofosfamid
1000 mg/m
Doxorubicin
50 mg/m
Vincristin
1.5 mg/m
Etoposid
60 mg/m
Se repet la fiecare 4 sptmni.
ICE
Ifosfamid
5.000 mg/m
I.V.
I.V.
I.V.
I.V.
ziua 1
ziua 1
ziua 1
zilele 1-5
I.V.
ziua 1
sau
24
ziua 1
ziua 1
zilele 1 -3
VIP
Etoposid
75 mg/m2
Ifosfamid
1200 mg/m
Cisplatin
20 mg/m
Se repet la fiecare 3 sptmni.
zilele 1-4
zilele 1-4
zilele 1-4
Topotecan monoterapie
Topotecan
100 mg/m
Se repet la fiecare 4 sptmni.
zilele 1-3
zilele:1-5
RR 85% (RC 10%) la pacienii netratai; RR 47% (RC 12%) la pacienii prealabil tratai
STRATEGIE TERAPEUTIC
Boala limitat
Actual, rezultatele cele mai bune se obin prin asocierea concomitent precoce de CHT
(protocol EP) i RT n regim hiperfracionat (DT 45 Gy, 150 cGy x 2/zi) [22].
Boala extins
EP/EC (etoposid-cisplatin/carboplatin)
CAV (ciclofosfamid, doxorubicin, vincristin)
ACE (ciclofosfamid, doxorubicin, etoposid)
ICE (ifosfamid, carboplatin, etoposid)
IP (cisplatin-irinotecan)
carboplatin-irinotecan RR mai bune (34% vs. 24%) i prelungire semnificativ a supravieuirii fa de regimul EP
[Hermes et al., ASCO 2007]
Alte regimuri determin rezultate similare, dar au fost mai puin studiate sau mai puin
utilizate [25]:
25
Chimioterapia cu aceleai regimuri ca n boala limitat (BL), 4-6 cicluri, amelioreaz supravieuirea la pacienii
cu boal extensiv i reprezint cea mai eficace cale de ameliorare a simptomelor clinice (II,A).
n Europa, asociaiile cu doxorubicin (CAV) au fost pn de curnd standard n boala extins, dar regimul
etoposid-cisplatin este actual tot mai frecvent utilizat la aceti pacieni (II,A) [20].
Boala recidivat
URMRIRE
Recomandri ESMO 2005/2007:
Evaluarea rspunsului post-terapeutic este recomandat cel puin la finalul tratamentului, prin repetarea
explorrilor imagistice radiografice iniiale.
Nu exist nici o eviden c urmrirea pacienilor asimptomatici cu cancere bronho-pulmonare small cell este
necesar.
La pacienii care supravieuiesc pe termen lung monitorizarea pe durat mai lung este justificat de riscul de
apariie a celei de-a doua localizri.
O examinare specific este indicat numai cnd situaia clinic o impune [20,32].
26
Ardizzono A, Grossi F. Update on the treatment of smal cell lung cancer. Ann Oncol 2000;11(3):101-104.
Choy H, Pass IH, Rosell R, et al. Small cell lung cancer. In: Chang AE, Ganz PA, Hayes DF, eds. Oncology - an evidence based
approach. New York: Springer, 2006:595-603.
Hirsch FR, Matthews MJ, Aisner S, et al. Histopathologic classification of small cell lung cancer. Changing concepts and terminology.
Cancer 1988;62(5):973-7.
Ruckdeschel JC, Schwartz AG, Bepler G, et al. Cancer of the lung: NSCLC and SCLC. In: Abeloff MD, ed. Clinical oncology. 3rd ed.
New York: Elsevier Churchill Livingstone, 2004:1649-1744.
Ihde CD, Glastein E, Pass IH. Small cell lung cancer. In: DeVita VT Jr., Hellman S, Rosenberg SA, eds. Cancer: principles & practice
of oncology. 5th ed. Philadelphia: Lippincott-Raven, 1997:911-918.
Bonnie S, McKenna RJ, Movsas BM. Small cell lung cancer. In: Pazdur R, ed. Cancer management: a multidisciplinary approach. 8th
ed. New York: CMP Oncology, 2004:105-122.
Ihde D, Souhami B, Comis R, et al. Small cell lung cancer. Lung Cancer 1997;17(suppl.1):S19-S21.
Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111(6):1710-17.
Hoang T, Schiller JH. Carcinoma of the lung. In: Skeel RT, ed. Handbook of cancer chemotherapy. 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2003:216-230.
Horvat T, Dediu M, Trlea A. Cancerul bronho-pulmonar. Bucureti: Editura Universul, 2000:377-386.
Wolf M, Holle R, Hans K, et al. Analysis of prognostic factors in 766 patients with small cell lung cancer (SCLC): the role of sex as a
predictor for survival. Br J Cancer 1991;63(6):986-992.
Rawson NS, Peto J. An overview of prognostic factors in small cell lung cancer. A report from the subcommittee for the management of
lung cancer of the United Kingdom Coordinating Committee on Cancer Research. Br J Cancer 1990;61(4):597-604.
Murren JR, et al. Small cell lung cancer. In: DeVita VT Jr., Hellman S, Rosenberg SA, eds. Cancer - principles & practice of oncology.
7th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005:810-846.
Miron L, Mihescu T. Cancerul bronho-pulmonar: aspecte clinice i de tratament. Iai: EditDan 2002.
Johnson DH. Chemotherapy of small cell lung cancer. In: Pass IH, Mitchell JB, Johnson DH, Turrisi AT, eds. Lung cancer: principles
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Iai: Editura Kolos, 2005:182-217.
Miron L. Cancerul bronho-pulmonar microcelular. n: Miron L, Miron I, eds. Oncologie clinic, Iai: Editura Egal, 2001:695-679.
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27
Inciden
n Uniunea European incidena anual a cancerului pulmonar este 52,5/100.000, iar
mortalitatea anual este 48,7/100.000. Valorile pentru brbai sunt 82,5 i respectiv
77/100.000, iar pentru femei 23,9 i respectiv 22,3/100.000. NSCLC reprezint 80% din
totalul cazurilor de cancer pulmonar. Mortalitatea prin cancer pulmonar poate fi atribuit
fumatului n 90% din cazurile care afecteaz sexul masculin i n 80% din cazurile care
afecteaz sexul feminin.
Diagnostic
Stabilirea diagnosticului patologic ar trebui realizat n conformitate cu clasificarea
WHO. Principalele subtipuri histologice de NSCLC sunt adenocarcinomul, carcinomul
epidermoid (cu celule scuamoase) i carcinomul macrocelular (cu celule mari). Specimene
histologice sau citologice pot fi obinute de la nivelul tumorii primare, limfoganglionilor
regionali, leziunilor metastatice, sau din efuziunile maligne. Se recomand alegerea procedurii
cu invazivitatea cea mai mic.
Stadializare i evaluarea riscului
28
TxN0M0
Tis N0 M0
T1 N0 M0
T2 N0 M0
T1 N1 M0
T2 N1 M0
T3 N0 M0
T1/T2 N2 M0
T3 N1/N2 M0
Orice T, N3, M0
T4, Orice N, M0
Orice T, orice N, M1
29
Tratamentul standard de prim linie pentru pacienii cu status de performan bun este
chimioterapia de asociere care include sruri de platin i un alt agent citostatic ci
eficacitate dovedit (vinorelbin, gemcitabin, taxani, sau pemetrexed la pacienii cu
tumori al cror subtip histologic este predominant non-epidermoid) [I, A]. Ca
tratamente alternative pot fi luate n considerare combinaii de medicamente cu
eficacitate dovedit, dar care nu includ sruri de platin.
Un studiul clinic randomizat n care au fost inclui pacieni selectai cu NSCLC nonepidermoid avansat a artat c asocierea bevacizumabului la combinaia paclitaxelcarboplatin conduce la creterea supravieuirii fr progresia bolii (PFS) i a
supravieuirii globale (OS) comparativ cu chimioterapia singur. Un alt studiu clinic
randomizat a art c asocierea gemcitabin-cisplatin-bevacizumab conduce la
creterea PFS, dar fr creterea supravieuirii mediane (MS), comparativ cu asocierea
gemcitabin-cisplatin.
Un studiu clinic randomizat n care au fost inclui pacieni cu tumori EGFR pozitive
(IHC) a artat c adugarea cetuximabului la combinaia cisplatin-vinorelbin ca
tratament de prim linie conduce la creterea uoar a OS, ns nu i a PFS.
La pacienii cu tumori care prezint mutaii ale genei EGFR poate fi luat n
considerare tratamentul cu inhibitori ai domeniului tirozin-kinazic al EGFR (utilitatea
acestei abordri va fi clarificat n momentul finalizrii studiilor clinice care evalueaz
acest aspect).
n cazul pacienilor cu stare general alterat i la cei cu status de performan 2 poate
fi luat n considerare monochimioterapia [II, B].
Momentul iniierii i durata tratamentului paliativ de prim linie: chimioterapia ar
trebui iniiat cnd pacientul are nc status de performan bun. n prezent nu este
stabilit utilitatea efecturii chimioterapiei pentru mai mult de patru-ase cicluri.
n cazuri selectate poate fi luat n considerare posibilitatea de rezecie a leziunilor
metastatice unice [III, B].
Ca tratament paliativ al metastazelor cerebrale multiple se recomand iradierea
ntregului creier (en. whole brain radiotherapy).
30
31
Department of Oncology, Unit for Experimental Cancer Treatment, Rigshospitalet, Copenhagen, Denmark;
Medical Oncology Service, Vall dHebron University Hospital, Barcelona, Spain
*Corespondena se trimite la: ESMO Guidelines Working Group, ESMO Head Office, Via L. Taddei 4, CH-6962
Viganello-Lugano, Switzerland;
E-mail: clinicalrecommendations@esmo.org
Aprobat de Grupul de Lucru ESMO pentru Ghiduri Terapeutice: Februarie 2002, ultima actualizare August 2008.
Aceast publicaie nlocuiete versiunea publicat anteriorAnn Oncol 2008; 19 (Suppl 2): ii41ii42.
Conflict de interese: Autorii nu au raportat nici un conflict de interese
Annals of Oncology 20 (Supplement 4): iv71iv72, 2009 doi:10.1093/annonc/mdp133
Inciden
n anul 2002, incidena global a cancerului pulmonar n Uniunea European a fost
55,5/100.000, iar mortalitatea 50,6/100.000. Valorile pentru brbai sunt 87,7 i respectiv
80,1/100.000, iar pentru femei 24,8 i respectiv 22,4/100.000 (GLOBOCAN 2002,
http://www-dep.iarc.fr). SCLC reprezint 15-18% din totalul cazurilor de cancer pulmonar. n
ultimii ani incidena SCLC a sczut. Exist o puternic asociere ntre SCLC i fumat.
Diagnostic
Stabilirea diagnosticului patologic ar trebui realizat n conformitate cu clasificarea
WHO. n funcie de localizarea tumorii, pot fi obinute biopsii prin bronhoscopie,
mediastinoscopie, puncie sub ghidaj ecografic, aspiraie transtoracic, sau toracoscopie. n
locul biopsierii tumorii primare se poate utiliza biopsierea unei leziuni metastatice. Se
recomand alegerea procedurii cu invazivitatea cea mai mic.
32
33
34
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