Adeno Carcinoma of Lung
45-year-old male with stage 4 Adeno carcinoma of the lung. The tumor was found to obstruct the left superior lobe bronchus with subsequent subtotal athelectasis and retracted left hemi-thorax. The exam found diffuse thickening of the mediastinal pleura, lymphadenopathy and analogous formations of probable secondary nature. In the expert's opinion, if the patient is already at stage IV, he should not undergo surgery. He recommends combined endobronchial and external irradiation together with chemotherapy.
1. The expert's considerations about the treatment program.
2. centers of excellence in Italy
This is a 45 years old male with an Adeno carcinoma of lung diagnosed on October 2009.
No data has been submitted as to his clinical symptoms or regarding his present performance status. Apparently, at time of the request of this second opinion on October he was before treatment initiation.
Relevant data as to the tumor stage could be learned from a total body C.T. scan performed on October. The tumor was found to obstruct the left superior lobe bronchus with subsequent subtotal athelectasis of the superior lobe and retracted left hemi-thorax. There was diffuse thickening of the mediastinal pleura of the superior lobe up to the hilus level, corresponding to T3.There was lymphadenopathy extending to the subcarinal region, corresponding to N2. In addition, there was a report of "Analogous formations of probable secondary nature, in direct contact with the visceral pleura, appreciated in the apical and medial segment of the left inferior lobe, the dimensions of which are, respectively, 6 and 30 mm." These would classify the tumor as an M1." Therefore, based on the available data, the stage by the TNM system would be T3N2M1, namely stage IV, irrespective of the still missing data about additional organs such as the skeletal system.
Fibrobronchoscopy performed on October provides confirmation of an easily bleeding tumour protruding into the lumen "in the third distal of the main bronchus…totally obstructs the left superior lobe ".
Considerations about the treatment program:
1) If the patient is already at stage IV, he should not undergo surgery. Therefore, if a PET-CT scanning has not yet been performed this should be carried out as soon as possible, for establishing the best accurate clinical staging, before any treatment is undertaken.
2) If the stage is limited to IIIA or IIIB, the best chances for cure are with concurrent chemo-irradiation. This should be followed by restaging allowing for surgery to be considered on the basis of eventual findings.
3) However, if stage IV is established, then a different strategy should be followed. This should be guided by the clinical manifestations of the disease and the general condition of the patient, with a more palliative approach. For example, if there is hemopthysis and/or decreased pulmonary function due to the obstructing endobronchial mass, I would strongly suggest consulting with radiotherapists regarding combined endobronchial and external irradiation as a first step in the course of treatment. This could be administered along with radiosensitization by reduced dose chemotherapy (either cisplatinum or paclitaxel).
4) In addition to the above detailed considerations, systemic chemotherapy is recommended aiming at prolongation of both time to progression and overall survival. There are various potentially effective options in this field. However, based on the histological type being adenocarcinoma I would suggest for the first line the combination of cisplatinum and pemetrexed. Since this regimen requires folic acid and vitamin B12 initiated at least one week prior to chemotherapy, this plan would be consistent with allowing the above suggested consultation regarding irradiation.
5) About the question of centers of excellence in Italy, I do not think there is any need for those with regards to chemotherapy and I would trust the treating team.