caz clinic 2015 lung cancer

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CANCER BRONHOPULMONAR Prezentare de caz

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Page 1: Caz Clinic 2015 Lung Cancer

CANCER BRONHOPULMONARPrezentare de caz

Page 2: Caz Clinic 2015 Lung Cancer

• 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

Page 3: Caz Clinic 2015 Lung Cancer

• CT cerebral• Leziune parietala stg (2

cm diametru)

• CT pulmonar + abdomen sup.

• tumora in LSS : cT1N0

• Diagnostic: cc.pulmonar statiul IV

• cT1N0M1

Page 4: Caz Clinic 2015 Lung Cancer
Page 5: Caz Clinic 2015 Lung Cancer

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) ?

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• CH: M+ rezecabila – ian 2006.

• HP: M+ de adenocarcinom, cu origine probabila in plaman

• M1 (6th TNM classification)• M1b (7th TNM classification)

Page 9: Caz Clinic 2015 Lung Cancer

Stadializarea cu acuratete – evaluarea mediastinului e importanta pt. prognostic si tratament optimal Cum stadializam?

• PET-CT ?• CT ?

Page 10: Caz Clinic 2015 Lung Cancer

• 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

Page 11: Caz Clinic 2015 Lung Cancer

Ce tratament ar fi optimal daca boala la nivel toracic este rezecabila?

• CH ?• Fara CH?

Page 12: Caz Clinic 2015 Lung Cancer

• 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)

Page 13: Caz Clinic 2015 Lung Cancer

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 ?

Page 14: Caz Clinic 2015 Lung Cancer

• Mutatiile activatoare EGFR sunt frecvente la paciente femei, nefumatoare, asiatice

References:Rosell R, NEJM, 2009Mok T, NEJM 2009

Page 15: Caz Clinic 2015 Lung Cancer

Ce tratament facem mai departe? • PCT ?• TKI-s ?• RTE cerebrala ?

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• Nu are evidenta bolii: RC post-opPCT “adj”. mart. – iun. 2006

• Cisplatin + gemcitabina, 4 cicluri

+• RTE cerebral – iun. 2006• 30 Gy

Page 17: Caz Clinic 2015 Lung Cancer

• 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

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• 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.

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• CT scans / torace si abdomen sup.: efuzie pleurala

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Mai faceti alte investigatii? • DA ?• NU ?

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• 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

Page 23: Caz Clinic 2015 Lung Cancer

• 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

Bibliografie: • 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

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• RP/ CT scan

• In Mai 2011, pacientul este in continuare in tratament cu Gefitinib.

• Pacienta este actual asimptomatica

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Tratament

• EGFR mutation la diagnosticul initial • Rolul CH la pacienti cu mutatii activatoare

EGFR - CH / cerebralaBrain- CH / Tu.primara

• Linia 1 de tratament – PCT (pe baza de PEM?) – PCT + bevacizumab ?– ALK + ? → Crisotinib in linia 1 ?

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