lung cancer - prezentare caz
TRANSCRIPT
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