GRACE :: Lung Cancer

Imaging and Response Measurement

Lung Cancer Imaging, Debate and New Issues

Is Progression-Free Survival Meaningful?

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Progression-free survival is something that doctors measure to determine how well a patient responds to a particular treatment. But does it translate to increased overall survival?

 


ALK Positive Lung Cancer Forum 2014: Disease Progression While on Xalkori

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New treatments for ALK rearrangements are on the horizon. In this video, the doctors discuss how they determine whether or not they change treatments for their patients once they begin to show progression while on Xalkori (crizotinib).

(IE/Firefox Users: If you have playback problems, please view on YouTube or try the “Download” button above. Get the latest QuickTime Player.)


ALK Positive Lung Cancer Forum 2014: Scanning for Progression

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How often should ALK patients receive scans to determine if their disease has progressed in various parts of the body?

(IE/Firefox Users: If you have playback problems, please view on YouTube or try the “Download” button above. Get the latest QuickTime Player.)


ASCO Lung Cancer Highlights, Part 2: Optimizing Radiation for Stage III NSCLC by Dr. David Gerber

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Improvements in radiotherapy techniques may allow increased dosesDr. David Gerber, University of Texas-Southwestern, reviews results from RTOG 0617 that help clarify the optimal dose of radiation for stage III unresectable NSCLC.

ASCO Lung Cancer Highlights, Part 2: Optimizing Radiation for Stage III NSCLC Audio Podcast


How Long A Period of Follow-Up is Long Enough to Be Confident a Ground Glass Opacity Won’t Grow?

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GGO over timeAn interesting article from Japan was published out in the Journal of Thoracic Oncology that asks how long a duration of follow-up imaging of a ground-glass opacity (GGO) is really needed to be confident it’s going to remain stable and not grow.   It’s very common to see small lung nodules that are ambiguous in their significance, for which follow-up scans are typically recommended rather than diving into a biopsy, and non-solid, hazy GGOs are another form of lung lesion that might possibly represent a lung cancer but are also the way a little inflammation or small infection would appear.   Even when they turn out to be something technically called cancer based on its appearance under the microscope, it’s often a non-invasive adenocarcinoma (sometimes termed bronchioloalveolar carcinoma, or BAC, but shifting in terminology to adenocarcinoma in situ, or AIS) or minimally invasive adenocarcinoma (MIA), in which the invasive component is less than 5 mm in diameter.  Even when they grow, it can be at an extremely slow pace.

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Dr. Heather Wakelee: How Should We Manage Acquired Resistance with a Single Lesion or More Diffuse Progression?

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Dr. Heather Wakelee from Stanford University offers her insights on how to approach a patient with gradual progression in a single site, especially in the brain, or more multifocal progression after a good initial response to a targeted agent for lung cancer.


Treating Bronchioloalveolar Carcinoma by Not Over-Treating It: What the Experts Really Do (and Don’t Do)

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I’m completing a chapter in a key lung cancer textbook on managing multi-focal bronchioloalveolar carcinoma, a clinical entity that is in the process of being re-labeled lepidic predominant adenocarcinoma (LPA) (lepidic meaning scale-like, which is the classic way that the cells are defined as spreading when looked at under a microscope). I suspect that it will continue to be called multifocal or advanced BAC for a long time (after all, the formal staging of small cell lung cancer goes from stages 1 to 4, but nobody ever uses that, classifying it as just limited or extensive stage).  

When asked to write this chapter, I faced the challenge of there being very little actual hard data on managing multifocal BAC.  Though many experts have a very similar approach, this is actually based on expertise, good judgment, and clinical experience more than data we can point to, and I don’t think this approach has ever been articulated in a scientific paper or book chapter, so I’m hoping this will be a valuable addition to the literature.

As I reviewed the papers out there, what struck me most are two things: 

1) There is incredible variability in the appearance and clinical behavior of what is called advanced BAC in the clinical world — some of it is aggressive and imminently threatening, and much of it is very slow growing and among the least threatening cases ever labeled as lung cancer.

2) People with a very slow growth rate are likely to do very, very well no matter what treatments they get, as much despite as because of those treatments.  In many cases, interventions are pursued on patients who are destined to do very well, and then when their short term survival is good, the people who did that intervention write a paper saying how their approach is feasible and attractive because the patients did well — not recognizing, or at least glossing over the idea, that they were going to do very well anyway.

I would say that in no other area of lung cancer care is it more important to distinguish between what can be done and what should be done.  And the real experts know when to not intervene.

So here is the algorithm I developed, which isn’t beautiful, but you can see that it focuses on seeing what is actually changing rather than treating reflexively based on a label on a pathology report or single a scan finding.  Essentially, it says to try to avoid intervening at all unless or until you see clinically significant change (which I would consider as something that is readily apparent as progression on scans done 6 months apart or less), and then if you see progression, clarify whether it’s limited to one lesion or progressing more diffusely in multiple areas.

Multifocal BAC algorithm

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The Challenge of Assessing Response in Malignant Pleural Mesothelioma (and Some Lung Cancers)

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Malignant pleural mesothelioma (MPM) is a challenging cancer to treat for many reasons, one of which being the difficulty in assessing whether there has been any meaningful change in the volume of a cancer that doesn’t tend to appear as a discrete mass, but most commonly as thickening of the pleura, the lining around the lung that is normally a thin, onion skin, but can thicken to be more like an orange rind or even thicker.  We can often see this pattern in some people with lung cancer who happen to have a form of the disease that also primarily appears as pleural-based deposits of cancer.

   Here’s a post I did for another site about this issue of imaging to assess response in MPM.  I hope it’s helpful to those of you with pleural-based disease.


What is the Biology Underlying a Mixed Response?

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As a second part of a recent video I did that introduces the concept of a mixed response in lung cancer (or many other cancers) and how we might manage that situation, I wanted to cover the biology of what is presumably occurring.  Here’s a video that covers this issue, as well as the implication that we can learn more about this by doing multiple biopsies, more than is considered as the typical standard now.

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Video: What is the utility of serum tumor markers in managing lung cancer?

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The question of whether and how to use blood tests, and particularly serum tumor markers, to monitor the status of a lung cancer has come up often here.  There are a few places where we’ve covered this in text, but for those of you who would prefer a video format for your information gathering, here’s a podcast I just did on that subject for Swedish Medical Center.

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