Recently, many postoperative patients have consulted me about postoperative adjuvant treatment, especially for stage Ib.
Many people are very confused about whether or not adjuvant treatment is needed and how to treat it.
So, take this case recently consulted to discuss with you.
Many people are very confused about whether or not adjuvant treatment is needed and how to treat it.
So, take this case recently consulted to discuss with you.
Medical history features: female, 53 years old, after radical resection of right upper lobe adenocarcinoma.
Postoperative pathology: invasive lung adenocarcinoma, 1.
0x0.
7cm.
Acinar type, adherent type, moderately well differentiated.
It suggests that the pleura is affected.
There was no invasion of lymph nodes, vessels, or nerves, and no indication of airway dissemination.
Genetic testing: EGFR21 exon mutation.
First of all, although the tumor itself is only 1cm, the attending doctor according to the pathology suggested that there is pleural invasion, and the patient is staged as pT2N0M0, which is stage Ib.
It should be noted here that this pleural invasion is not described in detail.
Clinically, pleural invasion is divided into 4 different levels according to different degrees.
Only when the tumor invades beyond the elastic layer, that is, PL1 or higher, will it affect the staging and become stage Ib.
Whether the violation exceeds the elastic layer, elastic fiber dyeing is required to confirm.
I haven't seen any description on this pathology report.
Therefore, here I suggest that the patient communicate with the attending doctor and the pathology department to further communicate the extent of this pleural invasion.
second question.
Even if there is pleural invasion, we cannot generalize these patients.
In the case of tumors less than 2cm, if the lesion is mainly ground glass before surgery, even if there is pleural invasion, it will not affect the prognosis.
(This part of the content has not been written into the guidelines, but the latest research results of Japanese scholars show this.
Many previous studies have shown that nodules dominated by pure ground glass will generally not recur and metastasize after radical surgery).
Therefore, here I suggest that the patient provide me with preoperative images.
Third, in the 2020 China CSCO guidelines, it is clearly stated that for stage Ib non-small cell lung cancer, including lung cancer with high-risk factors, adjuvant chemotherapy is not recommended because it is believed that chemotherapy cannot improve the prognosis and reduce the risk of recurrence.
(High-risk factors after non-small cell lung cancer surgery include: poorly differentiated tumors (pulmonary neuroendocrine tumors but excluding well-differentiated neuroendocrine tumors with vascular invasion, wedge resection, tumors> 4 cm, visceral pleural involvement, and unknown lymph node status.
)
However, the 2021 NCCN guidelines recommend adjuvant chemotherapy for stage Ib non-small cell lung cancer patients with high-risk factors after surgery, and recommend that patients who are not suitable for platinum-containing dual-drug regimens can receive oral osimertinib 80 mg/day.
This is a recommendation based on the results of the ADAURA study reported in this year's New England Journal of Medicine (NEJM) .
The results of the experiment showed that compared with placebo, osimertinib significantly prolonged the median DFS of patients with stage Ⅱ-ⅢA.
The median DFS of the two groups were not reached and 20.
4 months, respectively, which reduced disease recurrence by 83%.
Or risk of death.
In the total population (Ib-IIIA), the median DFS of the osimertinib group was also significantly better than that of the placebo group, which were not reached and 28.
1 months, respectively.
Therefore, after a comprehensive evaluation, my recommendations for this patient are as follows:
1.
In this case, adjuvant chemotherapy cannot improve survival and reduce recurrence rate, so adjuvant chemotherapy is not recommended.
2.
Whether assisted targeting requires a combination of two considerations: First, whether the preoperative image is mainly ground glass or solid components.
The second is the extent of large pathological pleural invasion.
If there are more solid components in the preoperative image, >25%, and the pleural invasion is confirmed by elastic fiber staining, and the extent of the invasion exceeds the elastic layer, it is recommended to take osimertinib as an adjuvant targeted therapy.
Can improve the prognosis.
The recommended targeted drug is the third-generation tki ossitinib, and the course of treatment is more than 2 years, up to 3 years.
It is not easy to be a thoracic surgeon.
It is not only a simple operation, but also a systematic and comprehensive disease management before and after the operation to improve the prognosis of the patient to the greatest extent.
However, clinical decision-making is often not so simple, and guidelines cannot be copied, and it is often necessary to combine the pros and cons of various aspects to make the final decision.
This requires our thoracic surgeons to continue to learn, keep pace with the times, and always act with humility and caution.
mutual encouragement.
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