Estadi I: cirurgia vs radioteràpia vs tècniques …...Carcinoma no microcític de pulmó. Estadi I: cirurgia vs radioteràpia vs tècniques interve ncionistes. Societat Catalano-Balear

Carcinoma no microcític de pulmó.Estadi I: cirurgia vs radioteràpia vs tècniques intervencionistes.

Societat Catalano-Balear d’Oncologia20 de Abril de 2010

Josep Belda SanchisCirurgià ToràcicHUMT-HSP-HM

1. Guies clíniques2. CBG en estadi inicial vs estadi I3. Anem a tractar un estadi I?4. Hem tractat un estadi I?5. Classificació R post-tractament6. Tractament sense diagnòstic7. Recurrència local8. Edat i comorbilitat

No hem resolt definitivament...



Patients should ask a simple question: "Can you describe the evidence for my treatment?“ For better or worse, the answer will tell you a lot about the care you're getting

Guies clíniques

Guies clíniques

Guies clíniques

2005

http://www.nice.org.uk/

http://books.gigaimg.com/avaxhome/big_show.php?/avaxhome/2007-10-11/1_424_orig.jpg

http://www.cancercare.on.ca/

http://en.wikipedia.org/wiki/File:NationalGuidelineClearinghouseLogo.png

http://www.hhs.gov/

Guies clíniques



CBG en estadi inicial vs estadi I

No defineix què és un estadi inicial; utilitza dos vegades aquesta paraula per referirse a:

1. Stage remains to be the most important factor, followed by age, and in early stage cases, gender.

2. Regarding a comparison of the two most common NSCLC lung cancer histologies, the squamous cell carcinomas may have a better prognosis than the non-BAC adenocarcinomas, particularly among males with early stage disease

IA IB

IB

IA

IA

Estadi II

T3N0

T4N0



12

3



Anem a tractar--Hem tractat un estadi I?

cT <10 mm 11-20 mm 21-30 mm

pN1/2 7% 20% 31%

Sv 5 a 85% 72% 56%

Descriptor T No diagnòstic Estadificació

SolimanIJROBP 2010

T1 61%T2 32%T3 5%T4 2%

9,3%

CT totsPET noGG òssia 73%MTC 12%

GrillsJCO 2010

T1 71%T2 29%

10%CT i PET totsMTC a criteri del metgesegons dades CT/PET

Timmerman JAMA 2010

T1 80%T2 (≤ 5 cm) 20%

0% CT i PET tots

20% SRT i 30 %wedge

Quins estadis I tractem?



Classificació R post-tractament




31 T1N0M0Adenocarcinomes perifèricsPrimer wedgeDesprés lobectomia



Tractament sense diagnòstic

Descriptor T No diagnòstic Estadificació

SolimanIJROBP 2010

T1 61%T2 32%T3 5%T4 2%

9,3%

CT totsPET noGG òssia 73%MTC 12%

GrillsJCO 2010

T1 71%T2 29%

10%CT i PET totsMTC a criteri del metgesegons dades CT/PET

Timmerman JAMA 2010

T1 80%T2 (≤ 5 cm) 20%

0% CT i PET tots

20% SRT i 30 %wedge

Characteristic No. of Patients (%)

Tumor classification, n=203

T1 118 (58)

T2 85 (42)

Maximum tumor dimension, cm

3-5 61

5.1-8 24

Medically inoperable 155 (80)

Refusing surgery 38 (20)

Pathologic confirmationNo 118 (61)Yes 75 (39)

Stage I nonsmall cell lung cancer in patients aged 75 years. Outcomes after stereotactic radiotherapy

Cornelis J. A. Haasbeek. Cancer 2010.

Bauman T1 70% 33% CT i PETJCO 2009 T2 30%



Recurrència local, regional,distància


Supervivència actuarial als 3 anys 56%

RTOG 0236

Supervivència actuarial als 3 anys 56%

26%17127/ 173cT2, > 7 cm29%19354/ 486cT3

30435268

MST

36%272/ 411cT2, >5-7 cm43%787/ 1345cT2, <=5 cm47%248/ 445cT1, >2-3 cm53%217/ 423cT1, <=2cm

5-YearDeaths / N

Overall survival by tumour size for patients with cT1-T3 N0, UICC 6 classification


Recurrència local, regional ,distància

5 yr rate of recurrence: 8%

Varying recurrence rates and risk factors associated with different definitions of local recurrence in patients with surgically resected, stage I nonsmall cell lung cancerVarlotto JM. Cancer 2010; DOI10.1002/cncr.25047. Radiation Oncology. Penn State Cancer Institute. Hersey, Michigan. USA

•Local recurrence increased nearly 2-fold when a broad definition was used instead of a narrow definition.

•Comparable definitions must be used when analyzing different series.


RTOG 0236 Grills JCO 2010 Bauman JCO 2009 Soliman IJROBP 2010

SV 5yr 56% CSS 30m 93% CSS 3yr 88% CSS 3yr 59%

No diag 0% 10% 33% 9%

Estadificació CT i PETCT i PET totsMTC 20% SRT i30% wedge

CT i PET totsCT tots, PET no73% GGOMTC 12%

RecurrènciaCT ↑ 20% iSUV PET compreQ o Biopsia

CT i SUV PETcom preQo Biopsia

Rx o CT i PETopcional si ↑ Rx, CT si Rx ↑

SRT



Edat i comorbilitat

El tractament quirúrgic disminueix amb l’edat: 1

– Perquè no se’ls ofereix (comorbiditat)

– Perquè refusen el tractament (el pacient o la família)

Sovint no se’ls ofereixen altres alternatives (QT, RT)

Edat i comorbilitat

40

45

50

55

< 65 anys65‐75 anys

> 75 anys

Supervivència

El llindar d’edat en el qual les lobectomies deixen d’aportar una major supervivència que les reseccions en cunya està entre els 65 i els 75 anys.

Edat i comorbilitat

Relacionada amb l’extensió de la

ressecció pulmonar

Edat i comorbilitat

Estem pendents de...

Estem pendents de...

Estem pendents de...RTOG 0618: A Phase II Trial of Stereotactic Body Radiation Therapy in the Treatment of Patients with Operable Stage I/II Non-Small Cell Lung Cancer

Eligibility Criteria

1) Non-small cell lung cancer (NSCLC) histologically confirmed by biopsy or cytology

2) Eligible patients must have appropriate staging studies studies identifying them as specific subsets of AJCC Lung 6th Edition, 2002 stage I or II based on only one of the following combinations of TNM staging:

a) T1, N0, M0 b) T2 (</=5 cm), N0, M0 c) T3 (</=5 cm), N0, M0 chest wall primary tumors only

3) Patients with hilar or mediastinal lymph nodes </= 1 cm and no abnormal hilar or mediastinal uptake on PET will be considered N0. Mediastinal lymph node sampling by any technique is allowed but not required. Patients with > 1 cm or mediastinal lymph nodes on CT or abnormal PET (including suspicious but nondiagnostic uptake) will still be eligible if directed tissue biopsies of all abnormally identified areas are negative for cancer.

4) The patient must be considered a reasonable candidate for surgical resection of the primary tumor according to the following criteria:

Estem pendents de...Trial of Either Surgery or Stereotactic Radiotherapy for Early Stage (IA) Lung Cancer

(ROSEL)Principal Investigator: Suresh Senan, MD, PhD; Egbert F Smit, MD, PhD VU University Medical Center

Study NCT00687986

First Received: May 28, 2008 Last Updated: May 18, 2009

Study Status: This study is currently recruiting participants.

Estimated Study Completion Date: December 2013

Estimated Primary Completion Date: December 2011 (Final data collection date for primary outcome measure)

M. D. Anderson Cancer Center to Lead Study of Surgery vs. CyberKnife(R) Radiosurgery for Operable Lung Cancer Patients

SUNNYVALE, Calif., Oct. 26 /PRNewswire-FirstCall/ -- Accuray Incorporated (Nasdaq: ARAY), a global leader in the field of radiosurgery, announced today that the company is partnering with The University of Texas M. D. Anderson Cancer Center in Houston, Texas to launch a prospective clinical study to compare treatment outcomes in early-stage operable lung cancer. Patients in the study will be randomly assigned to traditional surgery or CyberKnife(R) Robotic Radiosurgery for their treatment.

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Estadi I: cirurgia vs radioteràpia vs tècniques …...Carcinoma no microcític de pulmó. Estadi I: cirurgia vs radioteràpia vs tècniques interve ncionistes. Societat Catalano-Balear