No radiation, am I on the right track?

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November 19, 2015 at 11:16 am  #1271894    


Am I on the right track?. I was diagnosed stage 4 NSCLC – adenocarcinoma with no mutations in July 2015. Completed four rounds of carbo-Alimta and have just started Alimta maintenance. I’m a 54 year old female, otherwise good health, and have worked full time through all of this.
First Pet showed a 4.9 cm right hilar mass with encasement and obstruction of upper lobe bronchus SUV of 28. Now it’s 34mm, SUV 12.9 bronchus now patent but still encased with slight narrowing.
A t3 bone met SUV 16.2 is slightly smaller with SUV 4.9 with evidence of partial healing.
A left hip subcutaneous nodule 2.2 cm was SUV 23, is now distinctly smaller hazy streak of subcutaneous density suv 2.8.

My question is about radiation. My oncologist is not recommending it, saying she would only go that route for palliative purposes and reiterated the side effects. I’ve read about SBRT on people with just a few METS being beneficial. The high SUV on the lung tumor and its reduction of only 1.5 cm approx. have me wondering if it was reduced enough to be easily maintained as stable and if any type of radiation should be considered. Also, does Alimta generally maintain status quo or can it further reduce size and SUV?

Thank you for this website and all your hard work and time. What a huge resource this has been. You’re an incredibly caring group of people.

November 19, 2015 at 3:34 pm  #1271898    
JimC Forum Moderator
JimC Forum Moderator

Hi breezer,

Welcome to GRACE, and congratulations on your positive response to first line chemotherapy. Your doctor very correctly has stated the general principle that radiation is used in the stage IV setting only to alleviate pain or prevent damage to vital body structures. The exception that is sometimes made for oligometastases usually applies when just one metastatic site is involved in the hope that it is a kind of rogue location, the only place where cancer cells have spread. But when there are two bone mets that are widely separated, the assumption is that there are cancer cells in the bloodstream, not just in those two spots. Further, radiation to the lung can be difficult to tolerate, weakening the patient to the point that if progression occurs not long after the radiation, the patient may not be fit enough to receive the systemic treatment (chemo or targeted therapy) that he or she really needs. That’s not to say that such an aggressive approach is never done, but the risks must be carefully weighed against uncertain benefits.

Usually a patient receives the maximum benefit from a chemo agent such as Alimta in the first 4 rounds; further shrinkage is not common after that point. But some patients do benefit from extended periods of stability by continuing to use the same agent as maintenance therapy.

Good luck with maintenance Alimta.

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:

November 20, 2015 at 6:33 am  #1271903    


Good morning Jim and thank you for you time!

I actually only had one bone met to the spine. The tumor on my hip could be felt just below my skin and disappeared so quickly I hoped it was a cyst, but seeing the initial SUV does look like a distant met of some sort, as you said . I guess I was worried that the main tumor didn’t respond as well as the others and would progress faster with that high (I assume) SUV, but I am getting greedy perhaps :-). My oncologist seemed very happy with the response though.
I am going to a smaller clinic and want to be sure no stone is left unturned. Thank you again for your response!

November 20, 2015 at 10:44 am  #1271909    


Hi breezer.

Congratulations on your good response to the Carbo/Alimta!

We had a similar conversation with our Oncologist with similar answers. My wife (60yo, adenocarcinoma) had two small bone metastases (one front and one back) that were directly across from the location of the main lung tumor (middle right lung). He told us that radiation would not be good, and that he was going to consider radiation after the Carbo/Alimta (which worked well), but only if there was no progression for a long time and she wanted a break from the Alimta maintenance. My wife has just switched to Opdivo so the question for us is now moot.

If none of the standard mutations showed up with your tumor, you might want to discuss with your doctor the possibility of getting a mutational analysis done on your cancer. There are several companies (like Guardant Health) that can analyze your cancer non-invasively using a blood test, and our insurance covered it. While your mutation might not have any targeted therapies as of now, knowing your mutation could lead to particular therapies or treatments down the road, or might direct you to particular appropriate clinical trials.

All the best for a long and successful Alimta maintenance.


Wife, lifelong non-smoker, dx 4/24/15 adeno NSCLC stage IV, poorly diff. 2 bone mets, 1 lymph node. HER2 Exon 20 mutation. 6x Carbo/Alimta – >50% reduction in primary tumor, lymph nodes, & bone. Alimta maint. not effective, tumor growth, new liver mets. 11/15 – Opdivo; Not effective-add’l growth. 4/16 – clinical trial drug, large reduction of tumor and mets. 11/16-tumor growth, liver mets stable. 2/17-All Stable. 8/17- Add’l growth-off trial, 9/17 Gemzar- tumor reduction, then stable.

November 20, 2015 at 12:44 pm  #1271912    


If you’re not satisfied with the answer your onc gave you, get a second opinion with a rad onc.
Take care, Judy

Stage IIIA adeno, dx 7/2010. SRS then chemo carbo/alimta 4x. NED as of 10/2011.
Local recurrence, surgery to remove LRL 8/29/13. 5.2cm involved pleura. Chemo carbo/alimta x3. NED

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