Finished 4 carboplatin alimta avastin. What next?

Portal Forums Lung/Thoracic Cancer NSCLC Stage IV NSCLC Finished 4 carboplatin alimta avastin. What next?

This topic contains 6 replies, has 3 voices, and was last updated by  masalovai 3 months ago.

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May 13, 2018 at 9:29 am  #1294402    

masalovai

Was dx poorly differentiated adeno mets in bones in February 2018. Just completed 4 cycles Carbo Alimta Avastin. Booked pet scan and brain mri for 21 May.

My oncologist want to do open surgery biopsy to check for mutations because my previous two needle ones were unsuccessful due to lack of sample.

I really not sure if it’s right time for biopsy after four chemo…… I would go for radiation following by Keytruda or Keytruda combos with avastin or alimta. Then the biopsy could be taking from new growth in case of Keytruda failure.

I am afraid that all delays with future treatment caused by surgery complications and waiting for results of biopsy can cause progression. There is also no guarantee to get enough cancer cells after 4 chemos and the chance for mutations is very small in my case.in addition radiation can change mutations as well, so I can’t start with radiation before receiving biopsy results . In case if mutations even found , how radiation is working with targeted drug ….? And I believe I need radiation to treat bone mets….

I don’t understand why not to give a chance for immunotherapy to do the work first on pre padiated tumor and clear my bone mets, then to do biopsy if there will be new growth…….?

My medical insurance is not required pdl1 to use Keytruda in second line therapy .

Please help me to make right decision.

Many thanks

Irina

May 13, 2018 at 11:12 am  #1294403    

onthemark

Hi Irina,

Welcome to GRACE and I’m sorry that you have to deal with lung cancer. I had trouble following part of your description. It seems like you already had a biopsy to be told you have poorly differentiated adenocarcinoma. Was there not enough of a sample to also check for mutations?

My guess is that the best advise would be to decide on a treatment plan after your May 21 PET scan and brain mri. At that point I would get a second opinion from another oncologist since you have doubts about the recommendation of your present one. It seems like surgery to get a biopsy for metastatic cancer after chemotherapy is a big step and one I would also be hesitant about. If you have one or only a few isolated hot spots on the PET scan then I think radiation makes sense. if nothing shows up active on the PET scan then you wouldn’t need radiation at this point I.


10/2015 Chest xray found a nodule as part of a physical (no symptoms).
01/2016 Upper left lobe lingula preserving lobectomy stage 2b for 1.9 cm invasive adenocarcinoma with additional 2 mm AIS nodule found in pathology.
03-05/2016 Sixteen weeks of adjuvant cisplatin/vinorelbine.
07/2016 Durvalumab adjuvant clinical trial discontinued after 1st dose knocked out thyroid.
12/2016 Revised to stage 1b (due to VPI) after new guidelines for multifocal lepidic lung cancer.
07/2019 Next scan.

May 13, 2018 at 12:23 pm  #1294405    

masalovai

Thank you very much for reply. I also have patial lung collapse within the tumor side and this could add the problem to separate tumor from collapse during biopsy and get right sample.
Yes , there was enough biopsy sample for dx but not for mutations. I’ve done blood biopsy 3 months ago and it show no any mutations, but my oncologist consider blood biopsy as nor reliable enough.

May 13, 2018 at 5:02 pm  #1294406    

onthemark

My first thought is if it turns out you still have active metastatic disease, which you will know soon, it should be possible to biopsy one of the metastatic sites that would be less invasive than a lung surgery.


10/2015 Chest xray found a nodule as part of a physical (no symptoms).
01/2016 Upper left lobe lingula preserving lobectomy stage 2b for 1.9 cm invasive adenocarcinoma with additional 2 mm AIS nodule found in pathology.
03-05/2016 Sixteen weeks of adjuvant cisplatin/vinorelbine.
07/2016 Durvalumab adjuvant clinical trial discontinued after 1st dose knocked out thyroid.
12/2016 Revised to stage 1b (due to VPI) after new guidelines for multifocal lepidic lung cancer.
07/2019 Next scan.

May 13, 2018 at 7:13 pm  #1294409    
JimC Forum Moderator
JimC Forum Moderator

Hi Irina,

I think the first step is to see the results from your upcoming scans before making any decisions about future therapy. Those results will give you an idea about the efficacy of your fist=line chemotherapy. If you’ve had a good response, your doctor may suggest continuing with maintenance Alimta in an effort to keep the cancer under control for an extended period. Another option is “watchful waiting”, which entails keeping a close eye on the cancer through follow-up scans and clinical evaluations, and restarting treatment if progression is seen. Some patients find that a difficult concept to accept, but with Stage IV lung cancer it is often impossible to eliminate all traces of the cancer, so stable disease is considering a good result and may last quite a while. There’s a lot to be said for enjoying a treatment break, free from the side effects of therapy.

Without all the information available to your doctor, it would be difficult for us to evaluate the risks and benefits of an open biopsy – we don’t know why it was difficult to obtain sufficient tissue for mutation/PD-L1 expression testing. One observation is that it can be difficult to biopsy bone metastases, so it is probably not a viable option to obtain a biopsy from them. You state that your chance of having an actionable mutation is low. If that is because you have a significant smoking history, then mutation testing is not as likely to reveal an activating mutation, a factor that may influence your biopsy decision.

If your bone mets are causing pain or threatening to cause fractures, then radiation may be used to palliate symptoms and/or protect the bones. Many patients with EGFR or other mutations take a break from treatment for palliative radiation to bone mets, then resume the EGFR inhibitor without a problem. You needn’t worry about the radiation altering the mutational status.

[continued in the next post]


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

May 13, 2018 at 7:16 pm  #1294410    
JimC Forum Moderator
JimC Forum Moderator

[continued from the previous post]

Although your insurance doesn’t require high PD-L1 expression prior to Keytruda use, the evidence shows that the response rate is significantly better for patients who have high expression.

I wish there were a simple answer to your questions, but as is often the case with cancer, there are a number of factors that must be evaluated in order to make a decision. I’m hoping you can have a good discussion with your doctor about these factors.

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

May 14, 2018 at 2:21 am  #1294412    

masalovai

Thank you very much for all replies and advice. Will be waiting for test results and will speak to my oncologist again about future plans.

With best wishes
Irina

❤️

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