Really Stage IV?

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This topic contains 39 replies, has 8 voices, and was last updated by  Dr West 2 years, 1 month ago.

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April 4, 2012 at 11:16 am  #8632    

mk619

I was reading a posting by mikem (Another NED Report) and have decided to ask something I have been thinking about for a while. I have written about my sister-in-law on this forum several times in the past. She was diagnosed nsclc stage iv in 12/08 and started treatment in 12/09. Initial treatment was 6 rounds of cisplatin/alimta/avastin. Since 5/09 she’s been getting maintenance alimta/avastin, first every 3 weeks and now every 4 weeks. There has been no change in her status since she started maintenance nearly 3 years ago.

Her initial PET scan from 12/08 said: hypermetabolic uptake in the 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); two hypermetabolic contiguous nodules in the left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Her most recent PET scan was in 5/10. The only thing that showed on that was a 1.2 x 2.1 cm right lower lobe irregular lesion with very mild FDG uptake (SUV 1.1). No other abnormal hypermetabolic areas of uptake were noted in the lungs.

My question is if it is possible she really isn’t stage iv despite the fact there was some activity in the nodules in the left lower lobe and in the bilateral hila and mediastinum? Is it possible nothing ever moved beyond those areas? It doesn’t seem like her SUVs were terribly high when she was first diagnosed. She’s done remarkably well since diagnosis and I’m not trying to grasp at straws. But I am wondering if you’ve had experience with patients like this.

She’s scheduled a consultation with Julie Brahmer at Johns Hopkins in May. (She also saw Dr. Brahmer for a second opinion in 6/09.) Are there any specific questions you think she should ask Dr. Brahmer?

Thanks for your insights.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

  • This topic was modified 2 years, 2 months ago by  mk619.
April 4, 2012 at 12:30 pm  #8635    

mikem

Hi mk619,

I wanted to respond since you referred to my somewhat unusual history. The confusion on my staging came from the fact that they never biopsied the single lesion that was making me a stage IV. So I would pose that question to you. Were the lung nodules on both sides biopsied when you were diagnosed? If they were and both came back positive then you would surely be a stage IV. If they weren’t both biopsied then I think you have the right to question the staging. However keep in mind that there may have been something about the appearance of the scans that made the doctors sure that they were looking at cancer on both sides. I can’t blame you on this at all. I went for months before I finally questioned everything. The problem with that of course is that I will never really know if the lesion on my hip was cancer or not at the original diagnosis. But honeslty I’ll take the cards I’ve been dealt so far because I have been amazingly lucky. –mikem


56 year old former smoker diagnosed w/Stage IV NSCLC Adenocarcinoma 10/20/09 Completed 6 carbo/alimta followed by 10 Alimta maintenance. Biopsy of iliac negative for metastatic disease. Might not have been a stage IV after all. Oct. 2010, on to surgery…. removed lung. All lymph nodes clear 11-17-10. Jan 2014 Still all clear

April 4, 2012 at 12:56 pm  #8636    

mk619

The patient is my sister-in-law, not me so I’m not 100% certain. However, here is what the report from her initial consultation said: “The doctor ordered several tests to complete staging. A CT-guided fine-needle aspirate of the right lower lobe lesion was performed on 12/23/2008. Under pathologic review, the mass was consistent with adenocarcinoma. Immunohistochemical stains showed that the tumor cells were positive for TTF-1, CK7, CEA, ER (focally) and negative for CK20; consistent with a lung primary.” The report then continues with the PET scan results, I described above and MRI results, which were normal. Nothing else is said about any abnormalities.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 4, 2012 at 4:00 pm  #8641    

double trouble

Hi mk619. I’m sorry your sister in law is going through this. It is my understanding that diagnosis is not confirmed until, as mekem says, a tissue biopsy confirms it, but I’m a patient, so what do I know? If it were me I would be questioning the stage.
Debra


09/10 CT Bil. GGO’s 12/10 L L VATS Segment Adeno/BAC Kras+ 1st Primary Stage Ib
05/11 CT L Stable RU 1.3 cm nodule, 1r & 2r LN 08/11 PET/CT L Stable, mild uptake in R nodule, LN
09/11 EBUS N1, N2 LN Adeno+ 2nd Primary Stage IIIb
10/11 Start chemorad Cisplatin 11/11 Stop chemorad 4 cis/38Gy blood counts
12/11 PET/CT FDG neg 03/12 PET/CT Stable R nodule R hilar SUV 3.4 06/12 Growth R hilar SUV 9.5
07/12 Mayo recommends thoracotomy pneumonectomy EBUS R Hilar Adeno+
08/15/12 Brain MRI Normal 2nd Opinion Duke recommends VATS pneumonectomy
09/12 PET/CT hilar growth, new R 2.2 SUV 1.5 by 2 cm Hilar LN Kras+
Duke Mediastinoscopy R Lung Unresectable, Bronchoscopy #7 LN Adeno+ ALK+
10/12 HRCT 4 RUL nodules (3new) enlarging R Hilar
12/12 PET/CT 12/19 Start Xalkori 02/13 Decreased FDG R Hilar. RUL collapsed 05/13 Stop Xalkori begin rad x10 30gy
05/13 Hospital 6 days postobstructive pneumonia, cavitary abscess, complete rad
06/13 Bronchoscopy RUL RML blocked 07/13 PET/CT Decrease in size and SUV Hilar 09/13 Decrease in size and SUV Hilar, infection resolving

April 4, 2012 at 6:27 pm  #8660    

Dr West

It’s true that we can’t say with certainty that this was metastatic at the beginning without biopsies of a lesion that would prove it, but I don’t think that, without the benefit of hindsight demonstrating that she’s doing so exceptionally well, I would have doubted from the description that this was stage IV. The SUV is not just a raw number but is relative to the size of the lesion(s), so the lung nodules on the left would be sufficiently hypermetabolic if they were small, and usually hilar and mediastinal hypermetabolic disease in someone with known lung cancer represents the same process. I’ve seen a rare case with mediastinal and hilar lymph nodes that were sarcoidosis (an auto-immune, inflammatory process that isn’t cancer but looks exactly like it in these areas, including being hot on a PET scan), but it would be a tall order to ascribe everything else to a non-cancer process. My leading explanation would be that she has happened to do very well on treatment, which is great.

However, it’s fair to ask Dr. Brahmer, who will have the benefit of reviewing the scans and other details, whether she believes that’s a realistic possibility.

Good luck.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 4, 2012 at 7:36 pm  #8663    

mk619

Do you think it would be fair to ask Dr. Brahmer if she thinks radiation of the one remaining spot should be considered? What would be the downside to radiation in this situation?

I want to be clear that though I’m questioning the diagnosis I’m sure the hospital (Sloan Kettering) made a very reasonable diagnosis based on the scans. I’m just trying to figure out if we should be considering a change in treatment.

Thanks again for your insights.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 4, 2012 at 9:30 pm  #8666    

Dr West

I think it’s a very fair question. The downside would be damage from the radiation in the area and most likely wouldn’t be that severe, but it really depends on the location and how big the radiation field is.

And I didn’t take your question as impugning the place that did the initial staging. We sometimes see findings that make us question our initial assumptions that seemed very solid at the time. There’s a reason they say that hindsight is 20/20. You do the best you can with what you can know at the time, and there would be know way to know or suspect how much better she would do than what we might expect at the time that she presented.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 5, 2012 at 10:10 am  #8684    

mk619

Thanks, Dr. West. I think we’ve decided she should try to schedule a PET scan before she sees Dr. Brahmer next month since she hasn’t had a scan in almost two years. Hopefully the results will be good and it can help guide the discussion with both Dr. Brahmer and her doctors at Sloan.

Does that make sense? Anything else to consider?

Thanks again.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 5, 2012 at 4:53 pm  #8704    

Dr West

A PET scan is a very strong idea, since the whole concept of considering a local therapy is predicated on the viable disease appearing to be very isolated. This is more likely with a longer interval of follow-up before pursuing local therapy.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 6, 2012 at 7:52 am  #8728    

mk619

Thanks, Dr. West. Just want to confirm your last sentence. Are you saying if the next PET scan shows no change in that spot from the last scan two years ago local therapy might be an option? Meaning obviously that if there are any signs of progression local therapy is out?

Right now her doctor is willing to have the PET scan done, but is indicating she doesn’t expect a change in treatment based on that. The doctor’s position is they talked with a radiation oncologist a couple of years ago and the decision then was not to radiate unless that spot shows progression.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 6, 2012 at 11:01 am  #8737    

Dr. Weiss

When we consider local therapy to a specific spot, we very often get a PET. Here, the purpose of the PET is usually to make sure that there really is just one spot of concern. In other words, the PET is usually aimed to exonerating the rest of the body more than evaluating the spot where radiation is being considered.


Jared Weiss, MD
Lead Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or University of North Carolina. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 6, 2012 at 3:37 pm  #8742    

Dr West

Yes, I think the strongest argument for local therapy in the face of suspected or previously established metastatic disease is in someone who has no evidence of progression over a long time in areas outside of the one area of viable/progressing cancer.

If you’re interested, there’s more on the concept behind local vs. systemic risk in this post I just wrote, in part with thoughts of this kind of situation in mind:

http://cancergrace.org/cancer-101/2012/04/06/broadening-precocious-met/

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 9, 2012 at 11:19 am  #8826    

mk619

Thank you for the link. It was very interesting and encouraging. In my sister-in-law’s case although her initial diagnosis showed small spots in both lungs and hypermetabolic activity in some nodes, her last PET scan in 5/10 showed only a small right lower lobe spot with a SUV of 1.1. That scan was done about 4 months after she started treatment and when she had just finished 6 rounds of cisplatin/alimta/avastin. She is scheduled for a PET scan later this month. If that scan shows no change (or shrinkage) in that spot in her right lower lobe and no other progression in two years, might this spot be considered an example of a precocious metastasis?

Or could the argument be made that the alimta/avastin maintenance treatment she’s getting is what has kept her cancer from progressing and therefore not an example of precocious metastasis?

One thing I don’t know is what is on the actual scan. There might be more spots than are mentioned in the report. However, I hope the report is indicative of the scan.

Thanks again for your insights.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 9, 2012 at 12:14 pm  #8829    

certain spring

mk619 – Just wanted to say how nice it is to hear that your sister-in-law is doing so well. Very best.


49-year-old non-smoker, dx stage IV NSCLC May 2010 (squamous tumour of the left lung with multiple brain metastases). Radiotherapy to chest and brain; progressed through two cycles carbo/gemcitabine. Repeated lung collapses; pneumonia in collapsed lung, Nov 2010; bronchial stent placed, Dec 2010. Declined second-line Taxotere. Mutation testing Feb 2011, surprise EGFR exon deletion 19. Started Tarceva (150mg), Feb 2011. Progression in liver and elsewhere, May 2013.

April 9, 2012 at 2:58 pm  #8835    

Dr West

I wouldn’t say that this is quite the same as a precocious metastasis, which is when there is just one area that appears to represent spread of the cancer distantly. Having many lung nodules represents multifocal metastatic disease, but that doesn’t mean that local therapy wouldn’t be a consideration. Rather, in my mind it would fit more into the realm of the same situation as treating one area growing while everything else remains stable on a targeted therapy like an EGFR or ALK inhibitor in patients very sensitive to these. But in this situation, I think a stronger argument can be made for targeting a solitary area that is growing, against a background of controlled, stable disease, than for treating one area and really expecting that this will be curative. I would have to imagine that the rest of the disease is controlled but not completely eradicated by her ongoing treatment.

Also, there is a potential for radiation to interact in a negative (harmful) way with chest radiation, so I would suggest that this is reason to not be too cavalier about giving a therapy that is on weak footing in terms of justification and could have negative effects.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 10, 2012 at 2:07 pm  #8861    

mk619

Thanks, Dr. West. I think this is what the radiation oncologist at Sloan said a couple of years ago. She didn’t recommend radiation unless that one spot grows. We of course would love to think that there isn’t anything else there (we can wish can’t we?) and that maybe she could actually be cured with radiation. Call it our blue sky thinking, but I think it is something we will continue to ask about including when we see Dr. Brahmer next month.

But for now it seems likely her treatment will continue to be monthly infusions of alimta and avastin so I have few questions about that. Right now she’s getting treatment monthly and has been for more than a year. Do you know if it is possible to extend treatments beyond one month, maybe to 5 or 6 weeks? Also, do you know if it is possible to reduce the dosage? I’m pretty sure I’ve read about patients who have done that but my sister-in-law’s doctor is against that. Finally, if she took a chemo break and had progression could she go back on the alimta/avastin and hope for good results?

Thanks again for your insights.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 10, 2012 at 4:13 pm  #8865    

Dr. Weiss

None of the approaches that you describe are standard, but we’ve all done all of them at some point :) I tend not to extend alimta/bev more than every four weeks so I have no experience with those kind of longer schedules. I do often reduce dosage in the face of side effects. I have stopped chemo in many patients who had side effects or simply preferred to stop. If there is a long time (at least 6 months) without progression after stopping, then I consider restarting the same chemo to be one of the viable options and have done so with success. But if I stop and the cancer progresses quickly, then I often consider alternative chemo to be more promising for the patient.


Jared Weiss, MD
Lead Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or University of North Carolina. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 11, 2012 at 11:22 am  #8894    

mk619

How standard is it to use alimta/avastin in combo for maintenance? Mostly I read about alimta alone so I’m wondering if the combination is becoming more common and under what circumstances it is most often used that way (the two together).

Thanks again.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

April 11, 2012 at 12:30 pm  #8903    

Dr West

Either is very acceptable and commonly used. Most commonly, if they’re used together as maintenance therapy, it’s as continuation maintenance therapy after a combination of a platinum with Alimta (pemetrexed) and Avastin (bevacizumab) was used as first line therapy, and then the platinum was stopped after 4-6 cycles.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

April 26, 2012 at 9:34 pm  #9505    

mk619

Just wanted to give an update and ask a question. My sister-in-law had a PET/CT scan this week. Only thing that showed up was the same lower right lobe mass (2×1 cm) with the same SUV as three years ago — 1.1, which means it is virtually unchanged in three years. Her doctor is planning to present her case to the tumor board at Sloan Kettering next week. What is the purpose of the tumor board? Could they make recommendations for a change in treatment? She’s also has a consultation scheduled next month with Julie Brahmer at Johns Hopkins. Thanks.


Sister-in-law diagnosed 12/08 with NSCLC Stage IV. Scan on 12/30/08 indicated hypermetabolic uptake in a 4.1 x 3.5 cm right lower lobe lung mass (SUV 11.18); FDG-avid 1.9 x 2.8 cm right lower lobe mass (SUV 9.95); 2 hypermetabolic contiguous nodules in left lower lobe (SUV 3.8); and hypermetabolic lymphadenopathy in the bilateral hila and mediastinum (pretracheal lymph node). Initial treatment was six rounds of Cisplatin/Alimta/Avastin. Good response to treatment so started maintenance Alimta/Avastin every 3 weeks in 5/09. Scan in 5/10 showed only a 1.2 x 2.1 cm right lower lobe irregular lesion with an SUV of 1.1. No other hypermetabolic areas of uptake were noted. Increased time between treatments to 4 weeks. PET/CT scan in 5/12 showed virtually no change from 5/10. Core biopsy indicated no evidence of disease. Case presented to Tumor Boards at Sloan and Johns Hopkins in June. Boards at both were split in what to do so decision was to stay with current treatment for now. October 2012 scan also shows no evidence of disease. Still getting Avastin/Alimta every 4 weeks though sometimes stretching it out longer.

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