GRACE :: Lung Cancer

Imaging and Response Measurement

Lung Cancer Imaging, Debate and New Issues

What is the Current Role of Serum Based Biomarker Testing?




Drs. Ben Solomon, Leora Horn, & Jack West assess the utility and limitations of “liquid biopsies”, serum-based testing for molecular marker testing in lung cancer.

Download Transcript

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.



Dr. West:  At the World Lung meeting, we saw more new data and materials being promoted about serum-based testing of biomarkers — certainly more than I’ve seen at a prior meeting, and it seems like the technology is approaching a cusp of true clinical utility. What are your thoughts — how are you using serum-based testing, or even urine-based testing, I’ve seen little bit of work one, is that something that you’re using at all now, is it something that you think is fast-approaching, or still kind of in the distant future and inferior to tissue-based testing? Ben, I’ll start with you.

Dr. Solomon: Yes, so, I think a challenge with lung cancer patients is getting serial biopsies, and now we’re in a situation where getting a repeat biopsy can actually change treatment, and the example of that is a patient with en EGFR mutation who’s progressing on what we now call first-generation EGFR inhibitors. If these patients have another biopsy of their disease that has progressed, that shows a T790m mutation, then they’re likely to benefit from a third generation inhibitor. But, for a lot of patients, these biopsies are difficult to get, and I think that’s the real place that plasma DNA testing is likely to first make a clinical impact, and things like T790m change over time. Technology like blood-based testing allows us to follow that in a patient in a very non-invasive manner, so I think that’s probably the first place that…

Dr. West:  And these drugs are really coming out, hopefully in the next few months, where there’s going to be a much greater demand for repeat biopsies of some type, whether it is tissue biopsies, or a so-called liquid biopsy — a blood serum test. Leora, what are your thoughts here?

Dr. Horn: So, Lecia Sequist had really nice data at ASCO, showing that there was good sensitivity with a blood-based testing for T790m. So, I think that it is something that’s going to be more readily used. It’s easier for patients, especially in smaller community settings where there may not be an interventional radiologist or an interventional pulmonologist who can readily go get tissue, and patients, if they know their disease is progressing, will want to switch. I think where it will get a little bit difficult is if we start using them routinely, and you see a patient on an EGFR inhibitor has now developed T790m in their blood, but their CT scan looks good, you know, are we going to be using this for monitoring, and what do you do in that situation?

Dr. West:  Yeah, I think that’s a different question of using it sequentially to monitor impending progression, or, you know, serum-based progression versus clinical progression. I personally feel like that would be a real mistake. We don’t have enough good therapies that we should discard any effective therapy too early based on a number that doesn’t have any good clinical correlate. To me, it’s like looking at a telescope and seeing a meteor coming in, you know, thirty years and freaking out about it now. Already, you could do things like PET scanning all the time, or use something as old as CEA levels — and sometimes we see people get taken off of chemotherapy, or a targeted therapy, that they’re tolerating well and their scans don’t change, but their CEA went from 33 to 40, and that triggered what I would say is an ill advised change, and I’d be afraid of someone seeing T790m on a blood test and making a change too early.

Dr. Solomon:  I agree, there is no current data that supports changing from a first generation EGFR inhibitor to a third generation, just based on the presence of a T790m mutation in blood, in the absence of disease progression, on the basis of the current data.

Dr. Horn:  I agree with you, but you’re going to see it, and that’s what I worry about.

Dr. West:  No doubt, we already see people getting taken off of treatments based on CEA levels or a PET scan — to me it seems like you’re just changing lanes in traffic, it’s not getting you anywhere faster, it’s just — don’t just stand there, do something, as if that’s a reason to make a change.

What is a Pancoast Tumor and How is it Best Treated?

GRACE Cancer Video Library - Lung



Dr. Eric Vallieres, thoracic surgeon, introduces us to and provides a brief history for the special case in lung cancer of a “Pancoast Tumor”, along with how its optimal treatment has evolved over several decades.

Download Transcript

How Did You Like This Video?

Please feel free to offer comments and raise questions in our Discussion Forums.



So, there’s a particular tumor called Pancoast tumor, or superior sulcus tumor. Pancoast was the name of a radiologist from Philadelphia who in 1932, and this is way before we had CAT scans, so this is on a plain chest x-ray, described individuals who showed up with enormous pain around their shoulder and down their arm, sometimes some changes in their facial expression, who had, on x-ray, a tumor at the top of their lung. Basically what it means is a tumor that’s not only involving the lung, but involving the structures at the top of the lung, which happen to be the ribs and the nerves that come out of your neck and go down into your arm, and also some vessels that come out. So, it’s a very busy area up here, a very tight area – there’s not a lot of room for growth there. And so that’s what these Pancoast tumors or superior sulcus tumors are — they are tumors, regular lung cancers, but it’s their location that defines that we call them that way, and the fact that they are invading these structures.

GCVL_LU-E06_Pancoast_Tumor_History_Treatment 1a ML.001

Back in the ‘50s, those tumors were considered 100% fatal — there was no survivor anywhere with those tumors. And then, there was a first survivor who was treated with radiation alone — survivor at three years. And then, in the late ‘50s, accidentally, there is a patient who had received some radiation therapy, and had a beautiful response, and that is, the pain all went away, and he’d heard of some surgeons in Dallas, thoracic surgeons, who were quite good and aggressive, and he went to visit them and asked if he could have surgery, and they said sure. And the time that had elapsed, by the time he had finished his radiation, to the time he showed up in Dallas, was three weeks. So, it was radiation to 30 Gray, three weeks traveling and getting there, and then he had surgery. The surgery went much better than anticipated — the surgeons comments were, “this operation was easier than what we’ve seen in the past,” and what they found is that, the periphery of tumor was dead, but at the middle of the tumor there was still some cancer, and patients did well and recovered and lived. And as a result of that, they adopted this protocol, which we call the Paulson protocol, Paulson being one of the surgeons on the team, and that’s how we treated Pancoast tumors for years — 3,000 Gray, three weeks, surgery.

Until in the ‘90s, mid ‘90s, the Southwest Oncology Group (SWOG) ran a trial where, in addition to the radiation therapy, we added some chemotherapy at the same time, so a so-called concurrent chemo and radiation therapy, and then we took these patients to surgery afterwards. The results of that trial were so far better than anything else that we had seen before, that that has become the standard of care for the treatment of the Pancoast tumors — chemoradiation therapy, the dose of radiation being around 45 Gray, and then recovery, and then resection.

There’s also a study that was done in Japan about a few years later — very similar concept, different chemotherapy drugs, but very similar concept of concurrent chemoradiation therapy, recovery, and resection that showed identical results to those of the Southwest Oncology Group, and those two trials have established what we considered to be the standard of care for the resection of these Pancoast tumors.

Now, the operation is tricky because you just don’t remove lung — remember, those tumors are invading into the ribcage and the nerve structures at the inlet. So these operation can be very tricky, and may either involve a very high incision in the back, if the tumor is dominantly in the back, or if the tumor is more in the front, where the vessels are running, the incisions will be in the front. Again, those operations are — we do very few of those, in centers of excellence, and probably should be done by surgeons who have that experience. 

So, basically we went, before 1954, to a disease that was considered 100% fatal, now, in 2015, for individuals that we commit to this chemoradiation therapy and a resection, we’re looking at about a 60%, 4 to 5 year survival. That’s a major shift, a major improvement, in a relatively short period of time. 

The other improvement is that historically we considered individuals where their tumor was invading the spine, the vertebral column, not spinal cord, but the bones in which the cord is running — that used to be considered non-surgical. Today, because of advances in spinal surgery, we can combine these operations where we have a tumor that’s invading into the spine, going back to the descriptor, that’s considered a T4, because historically it was considered non-surgical, but today we can remove the spine and the lung altogether, and the reconstruction of the spinal column by the spine surgeon is quite amazing, how they do things, and we can achieve very, very good results.

GCVL_LU-E06_Pancoast_Tumor_History_Treatment 1a ML.002

Now, some of those are also Pancoast, if they are in the spine, high up in the chest, but that concept applies to tumors all along the chest and the spine itself. That’s another major improvement in that arena, and we’re lucky here to have the spinal expertise where we can offer that to our patients.

Lung Squamous Cancer 201: Understanding Your Disease


In Part 1 of 2 videos about squamous lung cancer, Dr. Chad Pecot explains what doctors look for and ask about when diagnosing lung cancer, and how you can be sure you received the correct diagnosis.

Is Progression-Free Survival Meaningful?


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


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.)

Ask Us, Q&A
Lung/Thoracic Cancer Expert Content



GRACE Cancer Video Library - Lung Cancer Videos


Join the GRACE Faculty

Breast Cancer Blog
Pancreatic Cancer Blog
Kidney Cancer Blog
Bladder Cancer Blog
Head/Neck Cancer Blog

Subscribe to the GRACEcast Podcast on iTunes


Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon

Subscribe to
   (Free Newsletter)

Other Resources


Biomedical Learning Institute