1、潜在可切除IIIAN2患者手术治疗的优势与挑战,PP-PM-CN-0281,背景,预后和治疗异质性广泛；放化疗手术多学科处理；目前仍未达成统一模式；新辅助靶向治疗缺证据；术后放疗未有充分证据；鼓励前瞻性的临床研究。,N2异质性,Subgroups of stage IIIA-N2-8th TNM staging,Goldstraw, et al. J Thorac Oncol 2015, IN PRESS,Subgroups of stage IIIA-N2-Robinson classification,Robinson LA, et al. Chest 2003;123:202S-220S
2、.,ACCP IIIA-N2 分类,外侵团块型N2,非融合N2,偶然N2,2013 ACCP guidelines 3rd ed. Chest 2-13;143,Subgroups of stage IIIA-N2-ESMO,2nd ESMO Consensus Conference in Lung Cancer stage III NSCLC. Ann Oncol 2015,偶然性N2治疗策略手术辅助化疗,2nd EMSO Consensus,潜在可切除N2治疗策略强调多学科综合治疗,In patients with discrete N2 involvement by NSCLC iden
3、tified preoperativey, we recommended the treatment plan should be made with the input from a mutidisciplinary team.,At a minimum a thoracic surgeon, medical oncologists, and radiation oncologist.至少有一个胸外科医生，一个肿瘤内科医生和一个放疗科医生参与制定治疗方案。,2013 ACCP guidelines 3rd ed. Chest 2-13;143,LJZ，女性，61岁，非吸烟者,2015-06-
4、12PET/CT: 右肺下叶结节，大小约2.1*2.4*2.1cm，SUVmax10.3，区域多发肿大淋巴结（4R、7、10R、11-14R）糖代谢不同程度增高，考虑右肺癌并区域淋巴结转移;,影像资料,临床诊断： 右下肺癌(cT1bN2M0， IIIA期),2015-06-16 行经颈纵隔镜检查术，病理提示： 淋巴结转移性腺癌（10/12；其中隆突下LN 5/7,右下 气管旁LN 5/5）；瘤细胞胞浆红染，部分呈印戒状。,病理诊断,印戒细胞 (X400),非粘液腺癌 (X400),基因诊断,ALK基因有断裂78%,免疫组化ALK（D5F3）（+）; EGFR基因突变（-），ROS1（-），cM
5、ET（-）， PIK3CA 4项（-）.,IHC: ALK +,初步诊断：右下肺印戒细胞腺癌 cT1bpN2M0 IIIA期(ALK+),Intergroup 0139IIIA NSCLC同步放化疗后手术对比非手术,Albain KS,et al. Lancet 2009;374:379-86,T1-3pN2M0N=429,随机,同步放化疗后手术 (n=202)放疗剂量：45Gy,同步放化疗(n=194)放疗剂量：61Gy,按方案完成放疗剂量的患者百分比:手术组：96% (193202) 非手术组：79% (154194) (P0.0001),主要研究终点: OS次要研究终点: PFS,PFS
6、,OS,OS matched lobectomy candidates (N=90),OS matched pneumonectomy candidates (N=90),Lancet.2015 Aug 11. pii: S0140-6736,23 centres in Switzerland, Germany and SerbiaPathologically proven, stage IIIA/N2 NSCLCAll patients were scheduled to undergo surgeryRandomly assigned 1:1 ratioChemoradiotherapy
7、group received three cycles of neoadjuvant chemotherapy (100 mg/m2 cisplatin and 85 mg/m2 docetaxel) followed by radiotherapy with 44 Gy Control group received neoadjuvant chemotherapy alone,新辅助放疗无获益，单纯新辅助化疗足够,Median event-free survival was similar in the two groups at 128 months (95% CI 97229) in t
8、he chemoradiotherapy group and 116 months (84152) in the chemotherapy group (p=067). Medianoverall survival was 371 months (95% CI 226500) with radiotherapy, compared with 262 months (199521) in the control group.,Lancet.2015 Aug 11. pii: S0140-6736,新辅助后（原发灶：1.0*1.0cm）,新辅助前 （原发灶：2.4*2.1cm）,新辅助治疗前后对比
9、,2015-6-12,2015-7-29,右下气管旁LN,隆突下LN,总体疗效评价PR（缩小58.3%）,新辅助化疗后 降期 vs.非降期,J Thorac Cardiovasc Surg 2011,141:48-58,2015-8-6拟行右下肺叶切除术+肺门纵隔淋巴结清扫术；术中冰冻LN：右肺门、下肺叶LN均提示淋巴结未见癌转移；术中由于叶间淋巴结与中叶动脉粘连，难以分离，决定行 中下肺叶切除术+肺门纵隔淋巴结清扫术。,手术R0切除,中下叶间LN,隆突下LN,病理诊断,右下肺浸润性腺癌，II级；淋巴结转移共3/20（冰冻送“后肺门LN”0/1，“下叶LN”0/2；后送“中叶LN”1/1；“叶
10、间LN”0/3；“上叶LN”0/1；“右上气管旁LN”0/4；“右下气管旁LN”1/2；“下叶LN”0/2；“隆突下LN”1/4）。,右下肺肿物 （HE - X100、X200）,R0切除的患者是否需要术后放疗？,手术质量控制,Quality of resection,R0R uncertainR1R2,R uncertain,Incomplete nodal stagingN2 removed in fragmentHighest N2 positiveExtra capsular extension,基因空间异质性,基因时间异质性,新辅助前,新辅助后,FISH: ALK 分离率63%,FISH: ALK 分离率78%,IIIA-N2肺癌总体策略,CTONG 1103 (EMERGING),
