9mm lung nodule and lytic rib lesion

Portal Forums Lung/Thoracic Cancer Work-Up/Staging of Lung Cancer 9mm lung nodule and lytic rib lesion

This topic contains 111 replies, has 6 voices, and was last updated by catdander forum moderator catdander forum moderator 13 hours, 49 minutes ago.

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November 11, 2016 at 6:20 am  #1289150    

Cheryl3700

Update: Got scans after 2 keytruda, reports mention good response in liver but also some increased lymph nodes. So mixed report and will continue with 2 more keytruda, scan again in 6 weeks.

Only part of report I don’t understand is this wording, can someone explain what it means? Is it indicative of a good or worse response?

“A 22 mm segment 5 lesion has become more cystic, probably indicating that the solid component has undergone further necrosis.”

Marching on into 20 months of stage IV. Happy Veterans Day.

November 11, 2016 at 6:48 am  #1289152    

Dr. Weiss

For all of the advances of immunotherapy (and there are many) one weakness is that we frequently know less where we stand as compared to when we treat with chemo. Mixed responses (some spots growing and some shrinking) and ambiguous scans are far more common. In my practice when there is ambiguity with immunotherapy, patients who feel well get a shot at staying on immuno in the hopes that it’s working; patients who feel poorly are promptly moved off of immuno onto something else. Also, if the possible progression looks “scary” to me for causing harm, I’m more likely to switch, while if it looks low probability for causing harm if it grows more, I’m more comfortable continuing the immuno. “Cystic” means fluid filled and “necrosis” means dead cancer. It can be good or bad. It’s good in the sense that we want the cancer to die and the death could be due to effective treatment. On the other hand, sometimes cancer grows so quickly that it outgrows its blood supply and dies as a cause of that. So, this is all explanation of the ambiguity. I hope that time proves that good things are happening!

November 11, 2016 at 10:01 am  #1289154    

Cheryl3700

Thanks so much Dr. Weiss for the explanation and information. I really appreciate your time and this site. It will be very interesting to follow my husband’s response with keytruda as he has not been tested for PD-L1, although his tumor is reported as MSS and I understand that could mean less likely to have PD-L1. I’m going to ask his onc at MGH what they think about adding a MEK inhibitor because I’ve read about a study on MSS paitients where that can boost response. :).

December 15, 2016 at 3:40 am  #1289550    

Cheryl3700

Update Dec 15, 2016 – Hubby feels pretty good, completed 4 keytruda now. Still no pain, no nausea. However having increased difficulty eating, lots of mucus builds and he has to choke it out. A few times it sounded like he is drowning in it. Got scans yesterday, won’t see dr till Monday. I looked at scans and it seems to me his liver looks really good, nice response. But something new is showing up in esophagus that was not in any prior scan. Maybe it’s just the mucus in there.

Question is, can keytruda have mixed results with one area showing response and another area obvious progression or new growth?

The waiting is hard. Thanks.

December 15, 2016 at 5:27 am  #1289551    
JimC Forum Moderator
JimC Forum Moderator

Hi Cheryl,

I’m glad to hear that your husband is generally feeling well, and that he appears to have had a good response in the liver. I hope that your meeting with the oncologist confirms your impression. Although it is possible to have a “mixed response” to treatment, a buildup of mucus can appear on a CT, so hopefully that’s all it is. You might want to check with his doctor, but over-the-counter Mucinex (or a generic equivalent) may help break up that mucus and provide some relief.

Many of us have experienced the anxiety of waiting for scan results, so we understand just how you are feeling. I hope that you get great results on Monday.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

December 22, 2016 at 5:59 pm  #1289604    

Cheryl3700

Update 12/22/16:. Met with onc on Monday who gave us great news that hubbys tumors have shrank in liver and some have disappeared. In esophagus, tumor is same size but showing signs of necrosis. All excellent news, onto 3 more keytruda and scan in 9 weeks.

On Tue night all of a sudden he started throwing up huge amounts of water and mucus for 9 hrs straight. Turns out he became blocked, was having increasing issues eating anyways. So now he has a stent in place. Recovering from that and will see how eating goes in a few days.

Merry Christmas folks.

December 22, 2016 at 10:21 pm  #1289606    
catdander forum moderator
catdander forum moderator

Dang Cheryl, Good news with what sounds like a disturbing bump in the road. Hopefully the stent will keep his esophagus open for good. Sometimes dying tumors cause there own set of issues. I’m so so sorry ya’ll are going through this during the holidays. Cancer is such a bully.

I have a feeling you and your husband will find many opportunities to have happiness in the days to come…hope.

Great news on the shrinking and stability!!!
Keeping you both in my thoughts.
Janine

December 23, 2016 at 10:04 am  #1289615    

Cheryl3700

Thanx Janine. I’m very shocked because he’s not been tested for pd-l1. Also he’s MSS and from what I read that means less likely to be pd-l1 positive. Only worried how long the keytruda will keep things going this way, like the folfox that stopped working at about 10 months, I’m expecting this will stop working as well. Who knows what other new something might be out by then though. It’s like a crazy race. Merry Christmas!

December 23, 2016 at 11:03 am  #1289620    
catdander forum moderator
catdander forum moderator

It is, like a crazy race. One that winners move as slow as possible. My money in on Hubby!
Merry Christmas with warm hugs!

January 9, 2017 at 7:00 pm  #1289740    

Cheryl3700

Hello, quick question about alk phos level. Hubbys kept rising last summer, lo and behold he ended up with mets to liver. New chemo didn’t work began keytruda, alk phos dropped quite a bit but it’s again rising and is higher than last summer. Just curious is a rise in alk phos normal when liver is responding to keytruda? Thanks!

January 9, 2017 at 7:12 pm  #1289742    
JimC Forum Moderator
JimC Forum Moderator

Hi Cheryl,

A look at the Keytruda prescribing information shows that about 28% of patients had elevated alk phos (see the chart at the top of page 13). So it’s not necessarily an indication of progression in the liver, but likely a rise due to the Keytruda itself.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

January 10, 2017 at 5:15 pm  #1289755    

Dr. Weiss

Alkaline phosphatase is a very non-specific marker. Causes of elevation (or fall when these factors are relieved) include: blockage of bile ducts in the liver (sometimes due to cancer, sometimes to other causes) and bone turnover (sometimes due to cancer, sometimes due to other causes). Changes in alk phos can sometimes suggest a new problem, but can never confirm it. Elevation of liver inflammation enzymes such as AST, ALT, and Alkphos are common with keytruda. When not very elevated, these can typically be monitored.

January 30, 2017 at 12:54 pm  #1289930    

Cheryl3700

Thanks for the info. Noting increased fatigue past few weeks. Alk phos has risen again, guess we will find out for sure if it’s due to progression or not with scans on Feb 14. Hopefully it’s going up due to keytruda itself. Always concerned.

January 30, 2017 at 6:03 pm  #1289935    
catdander forum moderator
catdander forum moderator

Keeping fingers and toes crossed for good scans. I’m so sorry you’re on “always concerned” status but very understandable.

Janine

January 31, 2017 at 5:34 am  #1289938    

Cheryl3700

Well well, since hubby has been so tired, I asked his onc to test his thyroid. Lo and behold his TSH is thru the roof at 47+ and is now on thyroid med. I was reading that keytruda can cause issues with thyroid. Now I wonder will it be permanent or not. Hopefully he will feel better in a few weeks when this med kicks in.

January 31, 2017 at 7:20 am  #1289944    
catdander forum moderator
catdander forum moderator

Yay Cheryl!

So glad that was just a bump in the road and you were there to get it looked at. I too have read immunos can cause thyroid irregularities. If the thyroid problem can be managed with meds and the immunotherapy otherwise keeps the cancer at bay then YAHOO! Your husband is lucky to have you on the front line of his care. I imagine/hope you know how important a role you play in his life. I’m sure he does.

Take care of yourself, easy to say but difficult to pull off when you’re in the trenches, I know. Keep people close who can help out including taking you out for a good time. I can imagine a pedicure would do wonders.

All best,
Janine

January 31, 2017 at 9:26 am  #1289946    

Cheryl3700

Thanks for the kind words Janine. Funny you mention a pedicure, I have never had one in my life. But hubby just came back from one as he likes them. lol I’m assuming his body will take a while to rebound from the low thyroid and for the supplement to work. Hoping his energy comes back. Next milestone will be scans in middle of Feb. End of March marks 2 years with EC. Long road, but looking at your hubby, I see an even longer road with you guys. Just amazing.

February 14, 2017 at 5:08 pm  #1290068    

Cheryl3700

Hi, just got back from latest scans. Hubby has had 7 Keytruda now and is due #8 on Friday. I’m the wannabe radiologist and I see continued response in Hubby’s liver tumors. I can’t tell what’s going on with esophagus because this is first scan with stent in place so hard to compare to last ones.

However, I believe I see possible pleural effusion in one lung. Can keytruda be working well but cause this issue? If so, what can be done?

Thanks.

February 14, 2017 at 5:45 pm  #1290069    
JimC Forum Moderator
JimC Forum Moderator

Hi Cheryl,

I hope you are right about the response. The appearance or increase in size of a pleural effusion, by itself, is not considered firm evidence of progression. Some patients have contnuing problems with recurring effusions even in the face of tumor response.

If the effusion is small and asymptomatic, your husband’s oncologist may want to watch and wait to see if it reduces in size, or at some point it might need to be drained. If it continues to recur, there is also the possibility of a pleurodesis, in which a substance such as talc is inserted into the pleural space, causing the inner and outer layers of the pleura to adhere to each other, preventing further fluid accumulation.

Hopefully it’s a good report all around, with no need to address an effusion.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

March 4, 2017 at 10:28 am  #1290266    

Cheryl3700

Written reports are in, there are pleural effusions in both lungs. What gets me is apparently 2 diff radiologists read his scans.

The one who read chest CT, reports; Circumferential thickening of the distal esophageal wall extending into the gastric cardia, with apparent increased size of posterior tumor bulk at the GE junction.

The one who read abdomen, reports; Distal esophageal mass is overall unchanged accounting for interval placement of a stent traversing the gastroesophageal.

Which is it, increased size or unchanged? Ugh.

Also read this; Of note, there is loss of the fat plane between the mass and the aorta. Looking online to see what this means, it could signal aortic invasion? If so, sounds scary.

They will scan again at 6 weeks from last one.

Such a tough ride.. keytruda #9 coming up the 13th.

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