Comprehensive treatment of advanced lung cancer survival may be extended

 Lung cancer is not incurable (c)
three multidisciplinary treatment can prolong survival in patients with advanced lung cancer of
see from the current treatment, surgery, radiotherapy, chemotherapy remains the treatment of lung cancer principal means. We have a clear understanding that a simple surgery alone a knife, too much emphasis on universal drugs, physical therapy unreasonably exaggerate the clinical behavior of lung cancer patients do not give a real clinical benefit. must be based on patients with lung cancer physical and mental condition, the exact location of the tumor, histological type, violation of the range (of disease) and the development trend, combined with changes in molecular biology, planned, scientific and rational application of existing comprehensive variety of effective treatment, the most appropriate The economic costs to obtain the best therapeutic effect, while maximizing the quality of life of patients improved. This is our years of emphasis on multidisciplinary treatment of lung cancer definition.
lung cancer clinical stage before surgery is essential. must be carried out before the operation stage scientific and standardized tests such as brain magnetic resonance imaging examination except for brain metastasis, whole body bone metastases than bone scan, abdominal ultrasound or abdominal CT than abdominal metastasis. These checks are both routine clinical diagnosis and treatment of lung cancer called , and it is given to reimburse departments at all levels of health care projects. lung cancer surgery must be regular cleaning of all mediastinal lymph nodes, which we call systematic lymph node dissection, only this operation to get an accurate staging of lung cancer, which is often the people we that the early, mid and late lung cancer. The development of our guidance and postoperative treatment is essential. postoperative chemotherapy and radiotherapy or not have to depend on the final pathological stage.
modern thoracic surgical techniques progress and surgical instruments, the rapid development of minimally invasive surgery, a new generation of chemotherapeutic drugs and modern radiotherapy equipment and technology of clinical applications, multimodality therapy for lung cancer has laid a solid foundation. needs to be noted that, minimally invasive thoracic surgical techniques and video-assisted thoracoscopic resection of lung cancer so that more elderly patients with lung cancer and poor pulmonary function to undergo surgery, after surgery most patients can be discharged in a week.
third-generation chemotherapy for lung cancer chemotherapy drugs and side effects of the new generation adjuvant, so that those who need to neoadjuvant chemotherapy before surgery and adjuvant chemotherapy after surgery to ensure the safe completion of full dose, so as to further enhance the long-term survival of patients with lung cancer.
rapid update of radiation therapy equipment and technology, the new generation of three-dimensional and four-dimensional positioning system guided by intensity modulated radiation therapy technology lock-in the tumor target organs, maximum protection against damage to surrounding healthy tissues and organs.
other words, the three traditional treatments have taken place in recent years major changes, three combination of modern treatment to more locally advanced non-small cell lung cancer has brought new hope. and all this academic leaders need to sense the exchanges and cooperation.
country in recent years has set up around a lot of lung cancer treatment center, gathered thoracic surgery, respiratory, oncology and radiation sciences leaders to jointly study the development of regional cancer prevention and treatment strategies for patients with lung cancer each study and formulate individualized multidisciplinary treatment program reasonable application of the full field of cancer treatment in recent years, new technologies and tools, and very Chinese characteristics, Chinese medicine treatment of lung cancer.
with lung cancer surgery and minimally invasive video-assisted thoracoscopic thoracic surgery and has undertaken the development of technology, TV Minimally invasive thoracoscopic surgery wedge lung resection, lobectomy of lung cancer has become the center of our routine operation. I and Ⅱ were non-small cell lung cancer patients can benefit from minimally invasive thoracic surgery.
common surgical procedure
VATS lobectomy is resection of lung cancer the most common surgical procedures.
bronchial sleeve lobectomy is mainly directed against forming a special group of central type lung cancer, bronchoscopy or violations prompted the tumor is located in lobe bronchus opening. Intraoperative frozen bronchial stump delivery has become a routine pathological examination.
resection of lung. gradually reduced in recent years, especially for elderly patients with lung cancer but also to carefully.
local excision: including segmental resection and wedge resection of lung . In recent years, video-assisted thoracoscopic resection of lung cancer patients to benefit senior citizens.
intrathoracic lung resection and systematic lymph node dissection is currently non-small cell lung cancer surgical surgical normative.
points to be emphasized :
1, preoperative clinical staging of lung cancer must be clear, the application PET, PET-CT and mediastinoscopy TV helps to obtain accurate clinical staging.
2, T1 ~ 3, N0-N1 and highly selective part of the N2 non-small cell lung cancer benefit from surgery, contralateral mediastinal lymph node N3 (IIIB period) and have pulmonary metastasis IV non-small cell lung cancer, surgical treatment can not bring long-term survival of the patient benefits.
3, postoperative adjuvant therapy is to improve the long-term survival of lung cancer and effective methods, including adjuvant chemotherapy and targeted therapy assistance.
check the preoperative staging of lung cancer and adjuvant chemotherapy are necessary . lung cancer patients choose the hospital and do not blindly rush to open surgery, preoperative brain magnetic resonance imaging examination must be carried out brain metastasis, whole body bone metastases than bone scan, abdominal ultrasound or abdominal CT examination after excluding the transfer decision abdominal surgery! that is, we often emphasize: we must first staging of lung cancer after treatment!
regardless of any form of lung resection surgery, surgeons should be routine intraoperative dissection of hilar and subcarinal lymph nodes and mediastinal lymph nodes! with histological type and staging to guide adjuvant therapy. In recent years video-assisted thoracoscopic lung resection advantages of minimally invasive surgical techniques are particularly prominent. Minimally invasive surgery for lung cancer for more than ten years of history, along with minimally invasive thoracic surgical techniques and TV Mirror surgical techniques and the accumulation of clinical experience, many hospitals have been able to complete thoracic surgery a variety of conventional video-assisted thoracoscopic minimally invasive thoracic surgery. The advantage is that trauma patients recover quickly, shorter hospital stay.
non- small cell lung cancer on adjuvant chemotherapy
growing threat to human health, morbidity, mortality increased significantly. including non-small cell lung cancer accounted for 80% to 85%, for early stage non-small cell lung cancer, complete surgical resection is the best treatment. But even the IA stage NSCLC, recurrence rate is still as high as 30% to R0 resection, 50% in patients with N1 metastasis and recurrence. intraoperative resection is not complete, potentially before surgery metastases and micrometastases led to local recurrence and distant metastasis after operation and decreased immune function in patients with lung cancer recurrence and metastasis is the main reason.
the face of this grim situation, adjuvant non-small cell lung cancer chemotherapy, attention has been paid. rational, systematic and effective multidisciplinary treatment, including adjuvant chemotherapy can reduce the risk of death compared with 13-15%%, will help prolong survival. Studies show that two drugs containing platinum 5-year program can 5-15% survival rate, with the advent of molecular targeted drugs for postoperative adjuvant therapy has brought new hope.
1. containing platinum in the adjuvant therapy of
has been completely resected non-small cell lung cancer adjuvant therapy received by all of the widespread controversy. Until recent years, adjuvant therapy became Ⅱ and Ⅲ A non-small cell lung cancer after standard treatment.
1995 years. long-term survival differences, although the results showed no statistically significant difference (P = 0.08), but in 2 years and 5 years, respectively, the absolute survival rate increased by 2% and 5% [1] .1995-2003 year period Many large-scale clinical trials, such as the Eastern Cooperative Oncology Group (ECOG) 3590 trial [2], and the Big Lung Trial (BLT) [3], the Adjuvant Lung Project Italy (ALPI) [4] were not obtained positive results.
2004 IALT year study. is by far the largest cases of randomized controlled study of postoperative chemotherapy. IALT enrolled a total of 1 867 cases of non-small cell lung resection, were randomized into two cisplatin-based Drug adjuvant chemotherapy group (932 cases) and not adjuvant chemotherapy in the control group (935 cases), the results show: 2-year survival rate of adjuvant chemotherapy group was 70-3%, 5 year survival rate was 44.5%, significantly higher than 66.7% and 40.4%, the difference was statistically significant (P <0.03) [5]. concluded: completely resected non-small cell lung cancer patients given platinum-based chemotherapy can improve the survival rate. NCI of Canada the same year, the JBR.10
test again confirms the above conclusion: enrolled 482 cases of completely resected stage Ⅰ B-Ⅱ non-small cell lung cancer patients were randomly divided into vinorelbine + cisplatin group and the control group. adjuvant therapy group were started within 6 weeks after surgery chemotherapy, vinorelbine25mg/m2 d1, 8,15,22 + cisplatin 50mg/m2 d1, 8, Q28days, a total of 4 cycles. The results showed that: compared with the control group, the auxiliary chemotherapy group, 5-year survival rate increased 15% (69% vs 54%, P = 0.03), mortality risk reduction 31% (P = 0.04), chemotherapy did not lead to excessive toxicity (only 2 cases of treatment-related deaths) [6]. This is the first right into the group of patients with third generation chemotherapy regimens in clinical trials, it is also the highest so far adjuvant chemotherapy improves survival .2005 reports the Adjuvant Navelbine International Trialist Association (ANITA) experiment into group of 840 cases of complete resection of the Ⅰ B-Ⅲ A non-small cell lung cancer patients were randomly divided into vinorelbine + cisplatin group and the control group were similar with JBR.10 trials, adjuvant chemotherapy improved 5-year survival rate of 9% ( HR 0.79, p = 0.013), but subgroup analysis showed that: Ⅰ B adjuvant chemotherapy of patients survive without the benefit (HR 1.10,95% CI 0.76-1.57) [7].
2005 年 Ⅰ B for the stage non-small cell lung cancer clinical trials CALGB9633 surface, into the group of 344 cases were randomly divided into 4 cycles of adjuvant chemotherapy and control groups. with paclitaxel plus carboplatin, the results showed that postoperative chemotherapy group and simple operation group 4 year survival rates were 71% and 59% (P =- 0.035). This is the first reported use of third-generation chemotherapy regimens as adjuvant chemotherapy for early stage NSCLC have statistically significant differences for the results of two studies in the adjuvant chemotherapy group, overall survival rate increased by 15% or more. But to make people disappointed that the 2006 ASCO Annual Meeting, 5-year survival rate of the experimental results, is actually a negative result, 5-year survival rate of adjuvant chemotherapy group 59% in surgery alone group was 57% (P = 0.375), the median survival time was 95 months for 78 months (P = 0.10) [8] makes Ⅰ b of the role of postoperative adjuvant chemotherapy for NSCLC has once again become uncertain factors.
2006 年 6 月 American Society of Clinical Oncology (ASCO) annual meeting of the CISCA (cisplatin vs. carboplatin) meta analysis of the results of the latest research, 9 clinical trials with 2,968 patients received cisplatin (1,489 cases ) or with carboplatin (1,479 cases), combination chemotherapy, including cisplatin and carboplatin in the RR were 30% and 24%, cisplatin chemotherapy improved response rate 37% (95% CI.16 -1.62; P <0.001). in the overall survival, than carboplatin, cisplatin 7% higher relative risk of death, but no statistically significant difference (95% CI :0.99-1 .15; P <0.101). sub-group analysis showed that cisplatin combination chemotherapy in non-squamous cell carcinoma patients had significant survival advantage, and in the third generation chemotherapy in a significant survival advantage [9]. But from the other hand consider the treatment of advanced NSCLC target is to improve the quality of life, reduce patient pain, only cisplatin and carboplatin, two drugs in terms of narrowly to survive the drug of choice there is a certain one-sidedness, and for the cure as the goal of early NSCLC, cisplatin in terms of response rate and survival advantage becomes essential. Therefore, based on existing research results, still combined with cisplatin-based chemotherapy as a third-generation standard adjuvant therapy program, and as a significant complication in patients intolerant to cisplatin instead of carboplatin.
the continuous advent of new drugs, but also for the adjuvant treatment of adding a new color. Recently, a German clinical trial of a TREAT Ⅱ include completely resected IB, II non-small cell lung cancer patients were randomly divided to, pemetrexed + cisplatin and vinorelbine + cisplatin group were for 4 cycles. As competition in the pemetrexed toxicity of superiority, the trial use of non-inferiority analysis, trials are now underway and we expect it of the result of [10].
2 non-platinum regimen in adjuvant therapy of
in Japan, due to toxic side effects, UFT has been a lot of clinical trials of all ages. UFT set (UFT) is a furan-fluorouracil (FT-207) and uracil (Uracil) 1:4 mixture by weight calculated to make the compound tablets, of which The West Japan Study Group for Lung Cancer surgery (WJSG) [11 ] and the Japan Lung Cancer Research Group (JLCRG) [12] and other studies have shown that UFT can improve after complete resection of non-small cell lung cancer survival. in which the latter into the group of 979 cases of patients with T1N0 or T2N0 adenocarcinoma, with a median follow-up time of 73 months, given daily oral UFT 250 mg/m2t2, the results of 5-year survival rate increased 3% (88% vs 85%, P = 0.047), in which T2 group, 5-year survival rate of 11% (85 % vs 74%, P = 0.005) .2005 Hamada, etc. In a related non-small cell lung cancer after UFT given assisted (UFT) chemotherapy for meta-analysis, including the nine clinical trials included 2003 patients selected, 98.8% were squamous cell carcinoma or adenocarcinoma, T1 to 1 308 cases (65.3%), T2 is 674 cases (33.6%), N0 to 1 923 cases (96.0%), with a median follow-up time of 6.44 years, with surgery alone group, the adjuvant chemotherapy group, 5-year survival rate increased 4.3% (81.5% vs 77.2%, P = 0.11), 7-year survival rate increased 7% (76.5% vs 69.5%, P = 0.001). for stage Ⅰ (particularly is T2N0) adenocarcinoma of the Japanese patients, oral UFT can significantly improve overall survival [13].
3 molecular targeted therapy as a new direction for adjuvant therapy of postoperative adjuvant chemotherapy
as non-small cell improve the survival of patients with lung cancer is limited, we have set our sights on the development of new drugs. In recent years, in the treatment of advanced non-small cell lung cancer in full swing in the development of molecular targeted therapy is gradually coming into the battlefield of adjuvant therapy. < br> E1505 Ⅲ clinical trials in North America, into the group object is the complete resection of the IB (tumor diameter greater than 4cm), II, IIIA non-small cell lung cancer stage were randomly divided into the chemotherapy group and the chemotherapy + bevacizumab (15mg/kg Q3w ), chemotherapy randomly selected NP, TP, GP these three kinds of programs, using cisplatin 75mg/m2, every 3 weeks, postoperative adjuvant chemotherapy for at least 6-12 weeks, the trial is ongoing, the ultimate goal is to include 1,500 patients patients, the survival hazard ratio combined bevacizumab group (survival HR) of 0.79. In addition, JBR.19 trial included more than 500 cases of complete surgical Ⅰ B, Ⅱ or Ⅲ A non-small cell lung cancer patients were randomly divided into Gefitinib and placebo groups. Unfortunately, due to Gefitinib in locally advanced and advanced non-small cell lung cancer maintenance therapy trials have been negative results, causing the pilot had to declare to stop [14]. RADIANT trial enrolled subjects complete surgical removal of both EGFR high expression (IHC or FISH positive) I, II, IIIA non-small cell lung cancer patients were randomly divided into erlotinib treatment group and placebo group, this study 945 cases of patients to be enrolled in order to evaluate the end of DFS, while analysis of EGFR and other biological markers in predicting the role of efficacy and prognosis.
tumor immunotherapy in a recent research focus is the people, in non-small cell lung cancer the role of adjuvant therapy has shown initial signs of Ni end. MAGRIT is an ongoing trial of immune therapy-related, into the group while completely resected MAGE-A3 positive I, II, IIIA non-small cell lung cancer, studies show that about 35-50% of the early non-small cell lung cancer Expression of MAGE-A3 positive. This trial enrolled 2,270 patients to be randomly divided into treatment group and the placebo group, treatment group after 6 weeks to give MAGE-A3 vaccine every 3 weeks, a total of 5 times, after every 3 months, a total of 8 times. test for the evaluation of the DFS endpoint, while adjuvant chemotherapy according to whether patients were stratified into the group.
4. Molecular biological marker of postoperative adjuvant therapy for ; possible
recent years, with the development of molecular biology, we use functional genomics and functional proteomics to detect in tissue or blood of patients with a biological marker to select the characteristics of effective treatment and possible drug patients with side effects appropriate treatment for their choice, so that the treatment of lung cancer to The role of drugs in the study become a hot, open the postoperative adjuvant therapy in the door of individual researchers IALT .2006 test results are analyzed, into the group of 761 cases of complete surgical resection of NSCLC patients with ERCC1 expression in tumor tissue situation. which ERCC1-negative (426 patients) were randomized to receive adjuvant chemotherapy significantly prolonged survival time, lower risk of death (HR 0.65,95% CI ,0.50-0 .86; P = 0.002), and ERCC1-positive patients whether or not adjuvant chemotherapy, There was no significant difference in overall survival. that ERCC1 expression was positive in patients with platinum-based chemotherapy may be from a benefit [15]. Zhong Z., etc. published in the journal in 2007, a pilot NEJM, 187 cases of NSCLC Patients I the pathological specimens were studied, analyzed the expression of RRM1 and survival of patients, ERCC1, PTEN were studied between. The results showed that the expression of RRM1 and ERCC1-related (P <0.001), but it has nothing to do with the PTEN (P = 0.37 ). RRM1 expression of survival was significantly better than patients with low expression patients (> 120 months vs 60.2 months; P = 0.02). RRM1, ERCC1 expression of survival are better (MST> 120 months). But the study found RRM1, ERCC1 expression was receiving high gemcitabine + cisplatin less effective [16]. The test results still need to be further confirmed by large prospective clinical trials.
short, with non-small cell lung cancer were treated with adjuvant chemotherapy to get the benefits of emerging evidence, II-IIIA completely after the operation of non-small cell lung cancer with adjuvant chemotherapy is the standard program. recommended to platinum-based medicine combined with the two programs and third-generation anticancer drug, UFT in Japan shows strong evidence of effective in patients with stage Ⅰ. The results of randomized clinical trials although adjuvant chemotherapy Ⅰ B, Ⅱ and Ⅲ A of the effectiveness of NSCLC and improve the cure rate to provide a reasonable and strong evidence, but still There are many issues we should continue to explore: such as which is more suitable for patients with adjuvant therapy? adjuvant treatment of choice where conventional program? the best adjuvant therapy treatment cycles? How to improve adjuvant therapy and treatment compliance and effectiveness? molecular target how to integrate drugs to adjuvant therapy, etc., these all look forward to more clinical trials to resolve.
molecular biology of lung cancer in the level of individual treatment to open the door, so that adjuvant therapy could enter a new era. With the depth of human understanding of their own, along with a number of targeted drugs and molecular markers related to the birth and in-depth study of individual treatment of lung cancer is increasingly approached us. With these new clinical treatment strategy for us is to improve the efficacy of lung cancer treatment and improve survival and laid a solid foundation supporting
Xuanwu Hospital, Capital Medical University Xiuyi Director of Thoracic Surgery, Capital University of Medical Treatment of Lung Cancer Center. in lung cancer diagnosis, surgery, and perioperative management and multidisciplinary treatment has extensive clinical experience. currently serves as Beijing Thoracic Medicine, director, member of China Association of Thoracic Surgeons, MD, Vice President and Director General, Tobacco Control and Lung Cancer Foundation of China, the work of Director, China popularization of anti-cancer Association and Beijing, Health Minister of Education Association executive vice president of the rank