2018.2.25 「強化治療」

之前有聽說「寡轉移」,今天又看見醫生post的話題:「強化治療」,陳太要來好好研究一下,下次回診蔡醫生和瑪麗醫院時,都要積極請教。

Although most NSCLC patients with sensitizing EGFR mutations (L858R, Exon 19 deletion) have an impressive initial response, the vast majority develop acquired resistance after 9-14 months of EGFR TKI therapy. Clearly, more effective strategies to prevent resistance emergence are needed. We recently reported a randomized phase 2 trial that showed that LCT with surgery or radiation, for molecularly unselected patients with oligometastatic NSCLC who did not progress after initial systemic therapy, improved progression-free survival (PFS) compared to maintenance therapy alone (Gomez, et al., 2016). Herein, we aim to determine the outcomes of LCT after first line TKI in patients with metastatic EGFR mutant NSCLC. Methods: This is a post-hoc analysis of our recently published phase 2 clinical trial and a retrospective review of MD Anderson Cancer Center GEMINI database. Eligible patients had metastatic EGFR mutant NSCLC, had first line TKI without progression followed by LCT with surgery or radiation. Results:In GEMINI database, 129 EGFR (L858R/Exon 19 deletion) mutant NSCLC patients were treated with first line TKI (erlotinib, gefitinib or afatinib) and 12 were treated with TKI followed by LCT (3 treated within our published clinical trial and 9 at the discretion of their physician). Among the 12 patients treated with TKI plus LCT, 8 patients had oligometastatic disease (defined as ≤3 metastases) and 4 patients had > 3 metastases. LCT regimens were hypofractionated radiotherapy or stereotactic ablative body radiotherapy for 11 patients and surgery for one patient. Patients treated with TKI followed by LCT had a significantly longer PFS (36 months) compared to patients treated with first line TKI alone (PFS 14 months, p = 0.0024, log-rank). Conclusions:Our retrospective data suggests that first line TKI plus LCT is a promising therapeutic strategy that led to a significant outcome improvement for patients with EGFR mutant NSCLC. A multicenter phase 2 clinical trial comparing TKI plus LCT to TKI alone is planned.

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腫瘤治療科 執行長 蘇志中

臨床上常見的兩種狀況,是晚期無法手術,對化學治療很有效,但無法完全讓腫瘤喪失(完全緩解),有人會說打到沒效時,換一組藥再打,到無效時,再換一組………,另一種狀況是原發腫瘤控制得很好,不幸後來出現轉移,在使用化學治療後,非常有效,但仍無法控制完全,於是有人說轉移的病不會好,換一組藥再打,無效時,再換一組………,這種漫無終止的治療,對病人真的是最好的選擇嗎?該病人終其一生都在化療,直到藥石罔效,對此我有不同的看法。

例:病患為31歲第四期肺腺癌患者,經八個療程化療(使用健擇),大部份的腫瘤及肋膜積水均消失,唯留下單一肺病灶未消退,一般均會選擇下一線化療,但病人身體狀況佳,且正子證實為單一殘餘病灶,建議使用〝立體定位放射線治療〞為強化治療之手段,使腫塊完全消失,其後再持續接受標靶藥物治療,追踪4年未見復發或轉移,此為以放射線治療作為consolidation therapy之成功案例。

癌症治療是最高境界,是讓病人在最不辛苦的狀況下,達到腫瘤的治癒之〝量身打造的治療計劃〞,所以只要能達到治癒的目的,就是好的治療方式。
除了部份腫瘤(如血液腫瘤、卵巢癌及性腺腫瘤)以化療之全身性療法,即可達到痊癒外,大部份的腫瘤均需要局部性的治療方式,如手術或放射線治療,不論在化療前或化療後,個人主張不需一味使用全身性的治療方式,來治療局部的問題;如果未使用〝強化治療〞(consolidation therapy),病患不但辛苦,直到化療無效後,會造成治療失敗的結果,以上為個人經驗,僅供參考(治療的節奏與邏輯是很重要的)。

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