You may have heard of MDT, the full name of which is “multidisciplinary team (MDT)” treatment, born in the United States in the 1990s, which refers to a multidisciplinary, multi-disciplinary approach that provides an individualized, comprehensive treatment plan, much like It is a multidisciplinary, multi-disciplinary approach that provides an individualized, comprehensive treatment plan, much like a multi-component team on the modern battlefield.
So how exactly does MDT work? Let’s take a look at what happened in Auntie Wang’s case.
Auntie Wang’s story
Auntie Wang is 60 years old, and she has had shortness of breath for 1 year, which has worsened significantly in the last 1 month. She went to a local hospital and had a chest CT, which showed a central type of lung cancer in the right upper lung, 4.2 × 3.2 cm, along with multiple enlarged lymph nodes in the mediastinum, which were considered metastatic.
After visiting Guangdong Provincial People’s Hospital, blood tests were drawn to suggest elevation of several tumor markers, including carcinoembryonic antigen (CEA) 6.02 ng/ml, non-small cell lung cancer-associated antigen (CYFRA21-1) 5.25 ng/ml, and neurospecific enolase (NSE) 14.58 ng/ml. peripheral blood tests also revealed EGFR gene exon 19 mutation.
Based on these findings, the physician considered the right upper lung mass to be malignant and made a clinical staging: cT2bN2M0 stage IIIA. The “c” refers to the clinical stage; “T” stands for tumor (Tumor), describing the size and extent of the tumor lesion, and Auntie Wang’s chest CT showed a maximum tumor diameter of 4.2 cm, which belongs to stage T2a; “N N” stands for lymph node (Lymph Node), the “multiple enlarged lymph nodes in mediastinum” on chest CT belongs to stage N2; “M” stands for distant metastasis (Metastasis), no distant metastasis is found, then it is labeled as metastasis. The first of these is the “M” for Metastasis, which is labeled as M0. Combining these three indicators, Auntie Wang’s lung cancer is at stage “IIIA”.
Subsequent PET-CT findings were consistent with this diagnosis: a soft tissue mass in the posterior segment of the upper lobe of the right lung (2.3 × 4.1 × 3.0 cm, SUVmax 7.5) and enlarged regional lymph nodes (right upper and lower paratracheal lymph nodes, the largest 1.6 × 2.8 cm, SUVmax 3.9), considered central lung cancer with regional lymph node metastasis.
First MDT discussion: tumor and mediastinal lymph node biopsy by EBUS recommended
Auntie Wang’s supervising physician invited specialists in pulmonary medicine, pulmonary surgery, and radiotherapy to join the discussion. The experts believe that malignancy is highly likely based on Auntie Wang’s condition, and that the clinical stage is stage IIIA. The treatment options for this stage are complex, and surgery, radiotherapy, and chemotherapy can be used either alone or with all three methods rolling up their sleeves together, so how to choose the most appropriate option for the patient’s condition? The experts discussed that in the absence of distant metastases, mediastinal lymph node staging is a key factor influencing treatment decisions, and therefore recommended performing ultrasound bronchoscopy (EBUS) to obtain a biopsy to clarify the presence or absence of mediastinal lymph node metastases and determine N stage.
So the surgeon performed EBUS on Auntie Wang and took a biopsy of the tumor tissue and enlarged lymph nodes.
Pathology suggested: right upper lobe invasive adenocarcinoma with adenocarcinoma metastasis in the right lower paratracheal lymph node. Molecular pathology suggests that there is an EGFR gene mutation [EGFR 19del(+)] and a negative ALK gene.
Second MDT discussion: determining treatment options
With this key information, Auntie Wang’s supervising physician convened a second MDT discussion, inviting translational center laboratory experts who are very knowledgeable about lung cancer driver genes, in addition to the previous experts.
Medical and radiotherapy specialists:
Aunt Wang was diagnosed with adenocarcinoma and an EGFR-sensitive mutation, staged IIIA-N2, with right lower paratracheal lymph node metastases and no distant organ metastases, and was first considered for a surgery-focused treatment strategy according to US and Chinese lung cancer guidelines. Surgeons are needed to first assess whether complete resection is possible and, if surgery is not available, to consider the current standard of care, concurrent radiotherapy.
Surgeons:
There are three elements to consider in the treatment of stage IIIA lung cancer.
1. The presence and number of mediastinal lymph nodes metastases.
From the imaging and EBUS results, according to the ESMO guidelines, Auntie Wang’s lung cancer was potentially resectable, but there was a risk of incomplete resection because PET-CT suggested multiple mediastinal lymph node metastases.
2. The extent of resection of the primary site.
By imaging, it is possible that the tumor has invaded the right main bronchus, and EBUS examination did not suggest neoplastic organisms in the right main bronchus and right upper lobe bronchial lumen, so right upper lung lobectomy for the primary focus is currently considered, but the possibility of right total pneumonectomy or sleeve resection cannot be ruled out.
3. Sequencing of treatment options.
In combination with the first two, right upper lung lobectomy + mediastinal lymph node dissection is currently planned, but neoadjuvant chemotherapy + surgery may be considered because of the higher risk of incomplete lymph node dissection if direct surgery is performed due to multiple stations of mediastinal lymph node metastasis.
A review after chemotherapy first reduces the risk of incomplete resection if N2 “downstaging” (reduction in tumor and lymph node invasion) can be achieved. If chemotherapy is not effective or even progressive, consider forgoing surgery and switching to concurrent radiotherapy.
Because of her EGFR exon 19 deletion mutation, treatment with EGFR inhibitors (gefitinib, erlotinib, erlotinib, etc.) should be effective, and experts have also discussed trying oral targeted drugs to “down-stage” the tumor before surgery. However, because there is a lack of high-level evidence to support this approach, it cannot be routinely recommended as a clinical practice.
Summary
Summary
Through two multidisciplinary expert discussions of Auntie Wang’s condition, we can see that the treatment strategy for stage IIIA-N2 lung cancer is complex and may involve multidisciplinary therapies, and that a multidisciplinary discussion among medical, surgical, and radiotherapy departments is necessary to develop the best individualized treatment plan.
Disclaimer:
Tumor disease and treatment options are extremely complex, and treatment should be fully individualized, and this case does not represent a “like patient” treatment decision. Please seek professional advice from your supervising physician regarding your specific treatment plan.
Co-authors: Dr. Zhiyong Chen, Guangdong Provincial People’s Hospital, Guangdong Lung Cancer Institute, China Dr. Jiatao Zhang