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NSCLC stage IIIA type of chemotherapy ?

NSCLC stage IIIA type of chemotherapy ?. Swiss tumor board Bern – 26.3.2009. Dr. Christian Monnerat Département Pluridisciplaire d’Oncologie – Hôpital Neuchâtelois Service de génétique médicale – CHUV - Lausanne. NSCLC stage IIIA (treated in 2004) Summary of the case presented by Dr. Morand.

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NSCLC stage IIIA type of chemotherapy ?

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  1. NSCLC stage IIIAtype of chemotherapy ? Swiss tumor board Bern – 26.3.2009 Dr. Christian Monnerat Département Pluridisciplaire d’Oncologie – Hôpital Neuchâtelois Service de génétique médicale – CHUV - Lausanne

  2. NSCLC stage IIIA(treated in 2004)Summary of the case presented by Dr. Morand 68 y. old, liver comorbidities, restrictive and obstructive pneumopathy Cytology : squamous cancer (G2 ?) obtained by bronchoscopy CT: 5 cm mass (left sup lobe) and bi-hilar ADP, liver ? (5 mm) PET-CT: no distant metastases, ADN near pulmonary vein (N1 ?) NSCLC cT2 cN1 cM0 = minimal stage IIB, possibly IIIA (no mediastinoscopy) Tumor resectable ? - yes Patient operable ? - yes

  3. NSCLC stage IIIANeoadjuvant chemotherapy - indications • Neoadjuvant treatment only in N2 stages • Chemotherapy • Chemoradiation http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf

  4. NSCLC stage IIIANeoadjuvant chemotherapy - indications Preoperative cisplatin-based combination chemotherapy can be considered in patients with stage IIIA N2 disease [II, B]. No pre-operative chemoradiation in Europe - SAKK protocoll ? http://www.esmo.org/education/esmo-clinical-recommendations.html

  5. NSCLC stage IIIANeoadjuvant chemotherapy using neoadjuvant therapy followed by surgery for known stage IIIA lung cancer as a routine therapeutic option is not supported by current published randomized trials t Combination chemoradiotherapy, especially delivered concurrently, is still the referred treatment… Robinson - CHEST 2007; 132:243S–265S

  6. NSCLC stage IIIANeoadjuvant chemotherapy – the pIII trials t no consistent surgical (pathologic) staging Variable numbers of much better prognosis or poorer prognosis patients small numbers of patients because of poor accrual Robinson - CHEST 2007; 132:243S–265S

  7. NSCLC stage IIIANeoadjuvant chemotherapy – the SAKK trial 90 patients with previously untreated, potentially operable stage IIIA (mediastinoscopically pN2) NSCLC 3 cycles of docetaxel 85 mg/m2 day 1 plus cisplatin 40 mg/m2 d1-2 ORR of 66% median dose-intensity 84.7 mg/m2 for docetaxel 94.6 mg/m2 for cisplatin. Clearance of N2 disease is a good prognostic factor for survival Betticher - J Clin Oncol 2002 ; 21:1752-1759.

  8. NSCLC stage IIIA(treated in 2004)Summary of the case presented by Dr. Morand 68 y. old, liver comorbidities, restrictive and obstructive pneumopathy Cytology : squamous cancer (G2 ?) obtained by bronchoscopy CT: 5 cm mass (left sup lobe) and bi-hilar ADP, liver ? (5 mm) PET-CT: no distant metastases, ADN near pulmonary vein (N1 ?) NSCLC cT2 cN1 cM0 = minimal stage IIB, possibly IIIA (no mediastinoscopy) Due to comorbidities (and age ?) , no neoadjuvant chemotherapy have the « chance » to escape from chemotherapy

  9. NSCLC stage IIIA(treated in 2004)Summary of the case presented by Dr. Morand 3.5.04 resection of left upper lobe and of apical segment of inferior lobe, arterial sleeve resection, central lymph node dissection pT2pN2(6/36), G2, extralymphatic spread of cancer, close to resection margin (R0?) Six cycles of weekly paclitaxel-carboplatin NSCLC pT2pN2(6/36), cM0 = stage IIIa Higher pathologic stage than clinically expected Recommandation of adjuvant chemotherapy

  10. NSCLC stage IIIAAdjuvant chemotherapy – meta-analysis NCCN, ESMO and AACP do agree on adjuvant chemotherapy Cisplatin : OS-HR = 0.89 - DFS-HR = 0.84 Pignon – LACE metaanalysis - J Clin Oncol 2008; 26:3552-3559

  11. NSCLC stage IIIAAdjuvant chemotherapy A persistent problem with postoperative chemotherapy has been administering the planned doses and cycles of chemotherapy Unfortunately, the experience of ongoing trials shows that the problem has not resolved and only approximately 65% of the planned dose of chemotherapy is actually received. Less toxic regimens are needed …(or « better » patients ) Patient is doing well after 4 years Have the 6 weekly paclitaxel carboplatin chemotherapy made the difference ? Robinson - CHEST 2007; 132:243S–265S

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