SWISS TUMOR BOARDLung Cancer

March 26, 2009Novotel Bern

Prof. Dr. Mahmut Ozsahin

Lausanne University Medical Center (CHUV), Lausanne

Case #1N. Mach

• Male patient, 79-yr-old

• Left lower lobe tumor (2.2 cm)

• PET: single + lesion (SUV 8) LLL

• Bronchoscopy (–)

• Percutaneous transthoracic bx: not done

• Diagnosis: cT1N0M0 lung cancer (stage I vs. infection (less unlikely)

• Decision: Observation**Patient refused surgery and radiotherapy

Case #1N. Mach

• Surgery is the standard treatment for stage I/II NSCLC

• If surgery not possible, localized RT

• Bad pulmonary function stereotactic extracranial RT (or Tomotherapy®, Cyberknife®, Novalis®) would be proposed (even without histological confirmation)

• No prospective comparison (medically inoperable patients)

Early operable NSCLC (stage IA, IB)

Surgery alone evidence level B

To have clear margins level A

Operation by trained surgeon level A

RT or re-excision for R1, R2 level B

Neo- or adjuvant RT for R0 level D

Adjuvant chemotherapy (stage IB) level B

Neoadjuvant chemotherapy level I

Smythe, Chest 2003

American College of Chest Physicians

RT is treatment of choice in medically inoperable or refusing patients (evidence level B).

5-yr. OS = 30% (meta-analysis)

No randomized comparison between RT vs. supportive care

Rowell, Thorax 2001

Early inoperable NSCLC (stage IA, IB)

Tomotherapy

Stereotactic RT

1x 30 Gy

3 months 6 months

Cybeknife

3x20 Gy

Case #1N. Mach

• Progression 9 months later

• NSCLC, non squamous; 5-cm mass LLL, no lymph node metastases

• Left pneumonectomy, pT2N1M0, re-stage IIB

• If R0, no indication for postoperative RT

• However, adjuvant chemotherapy is indicated (depending on medical conditions): IALT, European Big Lung, ALPI, ANITA, and meta-analysis (Pignon et al, J Clin Oncol 2008)

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

Intermediate stage II NSCLC