Progressed osteoblastic metastases in pelvic after pulsed tarceva for 8 months

Portal Forums Lung/Thoracic Cancer Lung Cancer Complications Bone Metastases Progressed osteoblastic metastases in pelvic after pulsed tarceva for 8 months

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August 13, 2013 at 10:55 pm  #1258628    


Hi Dr West,

I had diagnosed on Mar 2012, with mets to brain and bone.I am EGFR+ with 19 deletion. I took Tarceva since Apr 2012 and had great responses.

On Nov 2012, with still multiple tumors on my brain, I started pulsed Tarceva – I took 7 pills (150mg each) all at once on a day, then waited for 6 days. With less side effect, my brain mets(about 6-,7 of them, with largest 10mm) totally disappeared on Apr 2013’s scan. I continue taking pulsed tarceva since then.

Last week my CT scan shows small new appeared lung nodules (largest 3.5mm) and one slightly increased old nodule ( from 1.5mm to 3 mm), with SUV of max 1.3. And my PET scan showed extensive increase activities (suv 3.5) on my left sacral ala, corresponding to a 12mm sclerotic lesion.

I am now switched back to daily 150mg Tarceva since last visit and was told to wait for 3 more month for scan.

My question is: does this mean a tarceva resistance? Or it is caused by long period of pulsed tarceva? What might happen next after I switch back to normal Tarceva dose? What would be my option is the sacral ala lesion worsen?

We are all worried and would really appreciate any comments.


August 14, 2013 at 7:52 am  #1258630    
catdander forum moderator
catdander forum moderator

I’m very sorry you’re experiencing progression. I don’t know that anyone has enough experience with moving from pulsed tarceva. But I will contact a doctor to comment on your questions.

Below is a link to a treatment algorithm for acquired resistance and we also a plethora written on the subject.

I hope you do well on the new schedule.
forum moderator

August 14, 2013 at 10:16 am  #1258632    
Dr West
Dr West


I’m sorry to hear about your progression.

Yes, I would say that this progression likely constitutes acquired resistance, but it’s certainly possible that the disease outside of your brain will respond better to daily Tarceva (erlotinib) than to the pulsed Tarceva. There is absolutely no study of this approach, so there are no rules about what to call this or what to expect: the only way to know what will happen except to try it and see.

In terms of management options for the bone lesion, the main treatment approaches are systemic ones like Tarceva or chemo, which can treat bone metastases as well as other cancer lesions throughout the body, as well as radiation, which is often very effective in treating a focus of cancer that is causing pain or pressing on nerves.

Good luck.

-Dr. West

August 14, 2013 at 11:04 am  #1258634    


Thank you very much!

August 14, 2013 at 12:25 pm  #1258635    

Dr. Sequist

I agree with what Dr. West said and with your local doctor that it’s worth a try. If there is no sign of response on the next CT scan, I would consider getting a biopsy to try to determine the mechanism of acquired resistance to tarceva and then consider adding chemo to the erlotinib or trying a clinical trial. There are some promising drugs for tarceva resistance in clinical trials these days.

Best of luck!

Lecia V. Sequist, MD, MPH
Thoracic Medical Oncologist, Massachusetts General Hospital
Associate Professor of Medicine, Harvard Medical School

Views expressed here represent my opinion, not those of GRACE, Harvard Medical School, or Massachusetts General Hospital. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

November 8, 2013 at 12:12 pm  #1260384    


Hi Dr West and Dr. Sequist,

I came back from 3 month check up yesterday. The pelvic area stays the same (same SUV and same size); however, there are some activities on my lung, “evidence of multiple new focal areas of mild increased” “with SUV of 1.6 measuring 5mm vs 3mm on prior study..suggestive of worsening neoplastic lesion” on my PET report. Most of those new nodules are still in very small sizes (in mm) and SUV( less than 1), with total number of visible 6 to 8.

I am not sure if I should worry or not. The Doctor who produced this report would not know my change of Tarceva dose ( I changed from pulased to regular on August). My Onc considered this to be stable and request next 3 month CT only.

On the bright side, my brain are completed clean on yesterday’s MRI.

I would like to hear your opinion and suggestions.


November 8, 2013 at 2:53 pm  #1260396    
Dr West
Dr West

It’s certainly a judgment call, but this kind of progression by a few mm and a slight increased SUV on PET after several months is definitely in the range in which we might consider it to not be clinically significant progression and favor continuing without changes. It’s really in the eye of the beholder, actually seeing the scans and knowing the patient and how they’re tolerating treatment. But it’s very reasonable to hold off on changes based on subtle, asymptomatic (no symptoms — please forgive me if that’s insultingly obvious, but I think some people wouldn’t know the term) changes on imaging.

Good luck.

-Dr. West

November 8, 2013 at 9:26 pm  #1260406    


Thank you, Dr. West! I decided to hold off my worries until next scan.

January 31, 2014 at 10:48 pm  #1261877    


Hi Dr West and Sequist,

I am glad to report that, my last scan one week ago showed that all the new and old nodules were stable in size, after total 5 months of “progress”.

Thank you for your opinions and advice during my difficult time.

February 1, 2014 at 7:36 am  #1261880    
JimC Forum Moderator
JimC Forum Moderator

Great result! Thanks for sharing such good news!

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:

February 1, 2014 at 7:50 am  #1261882    
Dr West
Dr West

Congratulations! How very nice to hear! Thanks for sharing that good news.

-Dr. West

February 6, 2014 at 12:58 pm  #1262078    


Awesome to hear news like this!

Mom: 08/13: Dx Stage IV NSCLC Adeno. with mets to brain, bones, EFGR -, No ALK WBRT, Taxol/Carboplatinum doublet, good response 10/13: ER (Blood Clots) but CT Scan shows shrinkage in lungs and brain mets. GK on 1 remaining brain met. Transition to Alimta/Carboplat doublet; 12/13: Brain Mets inactive (scarring), Lung mass shrinkage. Tarceva/Aredia; 01/14: Dx LMC (bad); 02/11/2014: RIP Mom :(

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