1. SWISS TUMOR BOARD Lung Cancer March 26, 2009 Novotel Bern Prof. Dr. Mahmut Ozsahin Lausanne University Medical Center (CHUV), Lausanne

2. Case #1 N. Mach Male patient, 79-yr-old Left lower lobe tumor (2.2 cm) PET: single + lesion (SUV 8) LLL Bronchoscopy (–) Percutaneous transthoracic bx: not done Diagnosis: cT1N0M0 lung cancer (stage I vs. infection (less unlikely) Decision: Observation* *Patient refused surgery and radiotherapy

3. Case #1 N. Mach Surgery is the standard treatment for stage I/II NSCLC If surgery not possible, localized RT Bad pulmonary function  stereotactic extracranial RT (or Tomotherapy®, Cyberknife®, Novalis®) would be proposed (even without histological confirmation) No prospective comparison (medically inoperable patients)

4. Early operable NSCLC (stage IA, IB) Surgery alone evidence level B To have clear marginslevel A Operation by trained surgeonlevel A RT or re-excision for R1, R2level B Neo- or adjuvant RT for R0level D Adjuvant chemotherapy (stage IB)level B Neoadjuvant chemotherapylevel I Smythe, Chest 2003 American College of Chest Physicians

5. RT is treatment of choice in medically inoperable or refusing patients (evidence level B). 5-yr. OS = 30% (meta-analysis) No randomized comparison between RT vs. supportive care Rowell, Thorax 2001 Early inoperable NSCLC (stage IA, IB)

6. Tomotherapy Stereotactic RT

7. 1x 30 Gy 3 months6 months Cybeknife

8. 3x20 Gy

10. Case #1 N. Mach Progression 9 months later NSCLC, non squamous; 5-cm mass LLL, no lymph node metastases Left pneumonectomy, pT2N1M0, re-stage IIB If R0, no indication for postoperative RT However, adjuvant chemotherapy is indicated (depending on medical conditions): IALT, European Big Lung, ALPI, ANITA, and meta-analysis (Pignon et al, J Clin Oncol 2008)

11. Surgery alone evidence level B To have clear marginslevel A Operation by trained surgeonlevel A Postop RT for R1, R2 or pN2level C Adjuvant chemotherapylevel A Adjuvant RT for R0level D Neoadjuvant chemo + RTlevel D Scott, Chest 2003 American College of Chest Physicians Intermediate stage II NSCLC