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

2. Case #3 R. Morant 63-year-old woman, limited medical condition 5-cm mass in the left superior lobe, bihilar LAP ≤ 1 cm, 5- mm hepatic lesion PET: lung mass + ipsilateral hilar LAP, no liver lesion Moderately differentiated NSCLC (squamous-cell), cT2N1M0, clinical stage IIB Surgery: left lobectomy (upper and apical inferior lobe), pT2pN2 (6+/36), R0 but close margins; stage IIIA Board recommended postop RT/CT; patient refused RT, she received 6 cycles of paclitaxel/carboplatin Patient NED after 5 years

3. 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

4. The role of RT in operable NSCLC Postop RT To eliminate microscopic disease (positive margins, pN1, and pN2), or R2 disease Neoadjuvant RT + CT To increase pathological response; therefore, to obtain more R0 resections Final goal To increase survival by increasing loco-regional control

5. The role of postoperative RT in NSCLC PORT Meta-Analysis Trialists (PMT) Group Lancet, 1998 9 randomized studies Significant decrease in local failure 562 patients stage I, 7 of 9 studies using Co60, poor RT techniques, different levels of dose, variation in dose/fr., poor staging, etc.

6. The role of postoperative RT in NSCLC PORT Meta-Analysis Trialists (PMT) Group Lancet, 1998 Increased risk of toxic death (cardio-pulmonary toxicity) Adverse effect of PORT is: Greatest for patients with stage I/II, pN0-pN1 disease Benefit (?) for stage III, pN2 disease

7. Stage IIIA NSCLC Mediastinal LND evidencelevel A Neoadjuvant chemo + RTlevel B If unresectable  continue RT + CTlevel A Surgery level C Postop RT for R1-2level B Postop RT for R0level C Maintenance chemotherapylevel I Robinson, Chest 2003 American College of Chest Physicians