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SWISS TUMOR BOARD Lung Cancer March 26, 2009 Novotel Bern. Prof. Dr. Mahmut Ozsahin. Lausanne University Medical Center (CHUV), Lausanne. Case #3 R. Morant. 63-year-old woman, limited medical condition 5-cm mass in the left superior lobe, bihilar LAP ≤ 1 cm, 5-mm hepatic lesion
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SWISS TUMOR BOARDLung CancerMarch 26, 2009Novotel Bern Prof. Dr. Mahmut Ozsahin Lausanne University Medical Center (CHUV), Lausanne
Case #3R. Morant • 63-year-old woman, limited medical condition • 5-cm mass in the left superior lobe, bihilar LAP ≤ 1 cm, 5-mm hepatic lesion • PET: lung mass + ipsilateral hilar LAP, no liver lesion • Moderately differentiated NSCLC (squamous-cell), cT2N1M0, clinical stage IIB • Surgery: left lobectomy (upper and apical inferior lobe), pT2pN2 (6+/36), R0 but close margins; stage IIIA • Board recommended postop RT/CT; patient refused RT, she received 6 cycles of paclitaxel/carboplatin • Patient NED after 5 years
Intermediate stage II NSCLC Surgery alone evidence level B To have clear margins level A Operation by trained surgeon level A Postop RT for R1, R2 or pN2 level C Adjuvant chemotherapy level A Adjuvant RT for R0 level D Neoadjuvant chemo + RT level D Scott, Chest 2003 American College of Chest Physicians
The role of RT in operable NSCLC Postop RT To eliminate microscopic disease (positive margins, pN1,and pN2), or R2 disease Neoadjuvant RT + CT To increase pathological response; therefore, to obtain more R0 resections Final goal To increase survival by increasing loco-regional control
The role of postoperative RT in NSCLC PORT Meta-Analysis Trialists (PMT) Group Lancet, 1998 9 randomized studies Significant decrease in local failure 562 patientsstage I, 7 of 9 studies using Co60, poor RT techniques, different levels of dose, variation in dose/fr., poor staging, etc.
The role of postoperative RT in NSCLC PORT Meta-Analysis Trialists (PMT) Group Lancet, 1998 Increased risk of toxic death (cardio-pulmonary toxicity) Adverse effect of PORT is: Greatest for patients with stage I/II, pN0-pN1 disease Benefit (?) for stage III, pN2 disease
Stage IIIA NSCLC Mediastinal LND evidence level A Neoadjuvant chemo + RT level B If unresectable continue RT + CT level A Surgery level C Postop RT for R1-2 level B Postop RT for R0 level C Maintenance chemotherapy level I Robinson, Chest 2003 American College of Chest Physicians