Patient Case Discussion Advanced NSCLC Robert Pirker Medical University of Vienna

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Patient Case Discussion Advanced NSCLC
Robert Pirker Medical University of Vienna
ESMO International Symposium on Chest
Tumors Geneva, 30.3.-1.4.2007
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Case Discussion Advanced NSCLC

• A 62-year old man
• with symptoms of brain metastasis
• and a lung tumor

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Case Discussion Advanced NSCLC

• 62-year old male
• Smoker (40 pack years)
• No history of serious illnesses, no weight loss
• Developed severe nausea plus headache in Feb
  2001 collapsed on Feb 27, 2001
• Admission to hospital

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Case Discussion Advanced NSCLC

• 178 cm, 82 kg, ECOG-1
• Heart lung normal, RR 140/80, 80/min
• Liver spleen normal
• No enlarged lymph nodes
• No edema
• No signs of neurological deficits

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Case Discussion Advanced NSCLC

• MRI of the brain
  
  Lesion ( 2 cm) fronto-basal on the
  right site plus edema

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Case Discussion Advanced NSCLC

• MRI of the brain
  
  Lesion ( 2 cm) fronto-basal on the
  right site plus edema
• Chest X-ray
  
  Suspicion of tumor in left lung
• CT Scan of thorax upper abdomen
  Tumor left upper
  lobe ( 3.5 cm)
  No enlarged mediastinal lymph nodes
  Normal liver and adrenal glands
• Bronchoscopy
  Not done

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Case Discussion Advanced NSCLC

• 62-y old male smoker
• ECOG 1
• Lung cancer suspected
• Single brain lesion
• single lung lesion
• cT2N0M1
• clinical stage IV

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Question

• Which additional staging procedure(s) surgery
  would
• you perform?
• PET Scan
• 2) Bone scan
• Both PET bone scan
• Other(s)
• None

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Question

• Which of the following therapies would you
  recommend
• as initial therapy for this patient with NSCLC
  stage IV ?
• 1) Surgical resection of cerebral metastasis
• 2) Stereotactic radiosurgery of brain metastasis
  /-
• whole-brain radiotherapy
• 3) Palliative chemotherapy

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Case Discussion Advanced NSCLC

• Dexamethasone
• Resection of cerebral metastasis as initial
  therapy
• March 20, 2001
• Severe symptoms required rapid relief
• Squamous cell carcinoma plus large cell carcinoma
  with neuroendocrine features, compatible with
  NSCLC
• Rapid postoperative recovery
• Nausea headache disappeared
• Postoperative whole-brain radiotherapy
• 30 Gy (May June 2001)

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Brain metastasis

• Frequent in lung cancer
• Synchronous
• Metachronous
• Therapy
• Surgery
• Stereotactic radiosurgery
• Whole-brain radiotherapy
• Disease status outside of the brain must be
  considered

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Therapy of brain metastasisPeacock KH Lesser
GJ. Curr Treat Options Oncol 2006, 7, 479

• Surgery
• Single metastasis gt3.5 cm
• Immediate tumor relief necessary
• Pathological diagnosis required
• Small tumors with minimal edema surgically
  accessible
• Stereotactic radiosurgery
• Metastasis lt3.5 cm in surgically inaccessible
  areas
• Patients not suited fur surgery
• Small tumors with minimal edema (even when
  surgically accessible)

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Stereotactic radiosurgery
plus/minus whole-brain
radiotherapyAoyama H et al. JAMA 2006, 295, 2483

• 142 patients, 1 - 4 metastases (lt 3 cm)
• SRS SRSWBRT p value
• Os median 8 mo 7.5 0.4
• 1-year 28 38
• Brain relapse 76 47 lt0.001
• Salvage therapy brain ?
• WBRT decreases brain relapse rate but does not
  improve survival

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Brain metastasis

• Metachronous
• Better prognosis than synchronous lesions (33 vs.
  9 months from time of diagnosis of NSCLC,
  p0.001) but no difference from time of
  metastasis (12 vs. 8 months,
  p0.5)
  Flannery TW et
  al. Lung Cancer 2003, 42, 327
• Surgical resection whole brain radiotherapy
  
  Patchell RA et al. NEJM 1990, 322, 494
• Synchronous
• Resection of brain metastasis whole-brain
  radiotherapy
  Billing PS et al. J Thor
  Cardiovasc Surg 2001, 122, 548
• Surgical resection of primary tumor ?

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Question

• Which of the following therapies would you
  recommend for
• this patient after resection of brain metastasis
• Resection of the primary tumor
• Resection of the primary tumor followed by
  systemic chemotherapy
• Systemic chemotherapy
• None

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Case Discussion Advanced NSCLC

• 62-y old male smoker
• Surgery of primary tumor
  Lobectomy left upper
  lobe mediastinal lymphadenectomy (20.4.2001)
  
  complete tumor resection
• Final diagnosis NSCLC (squamous cell large
  cell carcinoma)
  pT2pN0M1
  
  pathological stage IV
  
  complete tumor resection

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Question

• Which treatment would you recommend for this
  patient after
• resection of the brain metastasis (plus
  whole-brain
• radiotherapy) and after resection of the primary
  tumor
• No further treatment
• Systemic chemotherapy

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Question

• Which of the following protocols would you use
  for
• systemic chemotherapy in this patient with good
  performance
• status and normal organ functions?
• 1) Cisplatin-based doublet
• 2) Carboplatin-based doublet
• 3) Non-platinum-based doublet
• 4) Other

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Case Discussion Advanced NSCLC

• Cisplatin/vinorelbine, 4 cycles
• July - October 2001
• Regular follow-up
• No further smoking
• CT scans thorax plus upper abdomen
  MRI of the brain
• Patient alive 6 years after initial diagnosis
• Last follow-up on Jan 24, 2007

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Unresectable NSCLC Follow-upASCO
guidelinesPfister DG et al. JCO 2004, 22, 3330

• History physical examination
• every 3 months during first 2 years
• every 6 months thereafter through year 5
• yearly thereafter
• Chest radiographs
• Only in symptomatic patients
• MRI brain
• Only in symptomatic patients
• Smoking cessation

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Case Discussion Advanced NSCLC

• Case 2
• 43-year old female smoker
• NSCLC IB (1999)
  lobectomy right upper lobe
  adjuvant chemotherapy
  (IALT)
• 2 metachronous brain lesions (June 2000)
  
  stereotactic radiosurgery of both lesions
  plus whole-brain radiotherapy
• Continuous clinical remission in 2007

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Case Discussion Advanced NSCLC

• Case 3
• 53-year old male smoker
• NSCLC IV (2005) with single brain metastasis
  surgical resection whole-brain radiotherapy
  lobectomy
  systemic chemotherapy
• Brain relapse (June 2006)
  stereotactic
  radiosurgery
• Currently stable disease

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Patient Case Discussion Advanced NSCLC Summary

• Brain metastases are frequent in lung cancer
  (synchronous, metachronous)
• Surgery, stereotactic radiosurgery, whole-brain
  radiotherapy
• Resection of single brain metastasis and primary
  tumor can result in long-term survival in
  patients
• with good performance status and
• absence of mediastinal lymph node involvement
• Resection or radiosurgery (/- whole-brain
  radiotherapy) of metachronous single metastasis
  can also result in long-term survival
• Not all of the treatment decisions were based on
  randomized trials

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Question

• Which therapy would you recommend for this
  patient with
• completely resected NSCLC stage IV ?
• 1) No further therapy
• 2) Adjuvant cranial irradiation
• 3) Chemotherapy
• 4) Chemotherapy and radiotherapy

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Case studyNSCLC

• Brain metastasis frequent in patients with NSCLC
• Patients with single brain metastasis lesion and
  single lung lesion benefit from
  surgical resection of both
  lesions
• Postoperative cranial irradiation systemic
  chemotherapy

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Surgery in NSCLC IV

• Resection of single cerebral metastasis
• Resection of lung metastasis
• Single lung metastasis rare at initial diagnosis
• Staging
• Secondary primary
• Resection of single bone lesion
• Palliative
• Resection of adrenal gland metastasis ??
• Resection of liver metastasis
• Single lesion is rare
• Far advanced disease