1. NSCLC Pancoast tumor Swiss tumor board Bern – 26.3.2009 Dr. Christian Monnerat Département Pluridisciplaire d’Oncologie – Hôpital Neuchâtelois Service de génétique médicale – CHUV - Lausanne

2. NSCLC stage IIIB (treated in 2004) Summary of the case presented by Dr. Zappa Palliative or curative option ?  82 y. woman, severe comorbidities (diarrhes, diverticulitis,hypecalcemia,…)  Biopsies : G3 NSCLC (squamoid) obtained by bronchoscopy  CT + PET-CT : upper left « huge » Pancoast NSCLC Palliative RT (or RT + CT)  Curative RT-CT (ev surgery ?)

3. Pancoast tumor curative intent ? Shen - CHEST 2007; 132:290S–305S Sulcus tumors or Pancoast tumors: Lung cancers in the apex of the chest, with ANY invasion of apical chest wall structures. Brachial plexus invasion not more required for definition Strong recommandation to perform a mediastinoscopy Staging work-up like other resectable lung cancers metaanalyses or large prospective studies of patients are not available

4. Pancoast tumor curative intent Shen - CHEST 2007; 132:290S–305S Chemoradiation followed by surgery if possible Chemoradiation alone Staging work-up like other resectable lung cancers Baltimore retrospective serie of 37 patients induction chemotherapy high-dose three-dimensional radiation (60 Gy) followed by surgery In 37 patients : complete resection rate of 97.3% complete response rate of 40.5% Overall median survival time was 2.6 years (7.8 years in the group with a pathologic CR) Kwong K, J Thorac Cardiovasc Surg 2005;129:1250–1257

5. Pancoast tumor palliative intent Shen - CHEST 2007; 132:290S–305S Palliative radiotherapy recommended in this case (age, comorbidities) radiation alone achieved good palliation of pain in approximately 75% of patients (Van Houtte P. Cancer 1984; 54:223–227) No long term survival if radiation alone (<5%) (Detterbeck FC, Pancoast tumors. Saunders, 2001; 233–243)

6. NSCLC stage IIIB Chemoradiation Jett - CHEST 2007; 132:266S–276S Standard : Concomittant chemoradiation  The optimal chemotherapy regimen to combine with RT is uncertain  Slight OS advantage : HR 0.87

7. NSCLC stage IIIB Chemoradiation (oral vinorelbine) Krzakowski M – J Thorac Oncol. 2008 Sep;3(9):994-1002.  TOX : G3 dysphagia/radiation in 4%  ORR 54%  Med DFS = 12.5 mo  Med OS = 23.4 mo  2 induction cycles :  oral vinorelbine 60 mg/m day 1,8 cycle 1 and 80 mg/m day 1,8 cycle 2  cisplatin 80 mg/m day 1 every 3 weeks for 2 cycles as induction  Radiotherapy 66 Gy (6,5 weeks) with 2 cycles of  oral vinorelbine 40 mg/m day 1, 8  cisplatin 80 mg/m day 1 every 3 weeks