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Clinical case Treatment for stage III NSCLC ERS 2016 M.J. Disselhorst, MD Dept. of Respiratory Diseases VU Medical Center, Amsterdam
Conflict of interest disclosure I have no real or perceived conflicts of interest that relate to this presentation 3
Aims Increase knowledge of best treatment options for stage III non-small-cell lung carcinoma Increase knowledge of EML4-ALK translocation 4
Case 54 year old man Medical history unremarkable Smoking history: 30 pack years, quit 9 years ago 5
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Case Pathology bronchoscopic brush RUL: malignant cells, TTF-1 positive 10
Stage A. T3N0M0 B. T4N0M0 C. T3N1M0 D. T4N2M0 11
Treatment A. Surgery B. Definitive chemoradiotherapy C. Induction chemotherapy and surgery D. Induction chemoradiotherapy and surgery 12
Meerbeek. 2007. JNCI. 13
Question What dose of radiotherapy is recommended for definite chemoradiotherapy in stage III NSCLC? A. 15 Gy B. 30 Gy C. 45 Gy D. 60 Gy 14
PFS Albain. Lancet. 2009 15
OS Albain. Lancet. 2009 16
R0 resections Shah. 2012. Ann Thorac Surg. 17
Question What treatment subgroup for stage IIIA-N2 NSCLC has best survival rates? A. Pneumonectomy after chemoradiotherapy B. Complete lobectomy after chemoradiotherapy C. Definite chemoradiotherapy D. Neo-adjuvant chemotherapy followed by surgery 18
Proclaim OS PFS Senan 2016. JCO 19
Question Which chemotherapeutic regimen has best toxicity profile in chemoradiotherapy in NSCLC A. Cisplatin etoposide B. Cisplatin gemcitabine C. Cisplatin pemetrexed D. Carboplatin gemcitabine 20
August October 21
Case Re-staging Mediastinoscopy 22
October December 23
4R October December 24
Pathologist calls. EML4-ALK translocation! Multidisciplinary board: how to adjust treatment? 25
Options A. Definite chemoradiotherapy B. Induction therapy with crizotinib and surgery C. Induction chemoradiotherapy and surgery D. Induction radiotherapy and surgery 26
Treatment Re-induction concurrent chemoradiotherapy Lobectomy 27
Lobectomy - pathology ypt2b N0 Mx R0 Pl0 28
Literature Albain et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet 2009; 374: 379 86 Antoni et al. Chemotherapy of locally advanced nonsmall cell lung cancer: state of the art and perspectives. Curr Opin Oncol 2016; 28(2): 104-109 Crino et al. Early stage and locally advanced (non-metastatic) non-small-cell lung cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann of Oncol 2010; 21(5): v103 v115 Fan et al. Clinicopathological and Demographical Characteristics of Non-Small Cell Lung Cancer Patients with ALK Rearrangements: A Systematic Review and Meta-Analysis. Plos one 2014 Goldstraw et al. The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. J Thor Oncol 2015; 11(1): 39-51 Kelly et al. Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non-small-cell lung cancer: SWOG S0023. J Clin Oncol 2008; 26: 2450-2456 Meerbeeck et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non small-cell lung cancer. J Natl Cancer Inst 2007; 99: 442 50 Ramnath et al. Treatment of Stage III Non-small Cell Lung Cancer - Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2014; 43(5)(Suppl):e314S e340s Senan et al. PROCLAIM: randomized phase III trial of pemetrexed-cisplatin or etoposide-cisplatin plus thoracic radiation therapy followed by consolidation chemotherapy in locally advanced nonsquamous non small-cell lung cancer. J Clin Oncol 2016; 34(9):953-62 Shah et al. Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Ann Thorac Surg 2012;93:1807 12 29