Resected squamous lung cancer and now adrenals suspicious

Portal Forums Lung/Thoracic Cancer NSCLC General NSCLC Resected squamous lung cancer and now adrenals suspicious

This topic contains 36 replies, has 5 voices, and was last updated by catdander forum moderator catdander forum moderator 3 weeks ago.

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March 19, 2016 at 6:12 am  #1273326    

volume

First of all I’d like to say that this site and its forums have been quite useful for me. Thanks to everyone who contributes and devotes their time to helping others!

My dad (72) was diagnosed in October with stage IB squamous lung cancer. Two weeks later he had upper right lobectomy. Histology read: poorly differentiated (G3) squamous cell lung cancer with massive necrosis. No lymph nodes involved. Doctors recommended adjuvant radiotherapy to the mediastinum, just in case and did 40Gy.

A post-surgery CT scan indicated suspicious bilateral adrenal masses 3.6 and 3.8 cm. The pre-operation scan indicated these adrenal masses as adenomas. Both pre- and post-operation CTs were done without contrast. (PET was not suggested by any of the doctors).

Now, 3 months after radiotherapy we did a CT with contrast which showed 3.3 and 4.8 cm masses in the adrenals. One of which has lower attenuation segments (the larger one).

Another important note is that over 1 year ago my father had an abdominal CT with contrast in connection with some kidney stones and the two masses in the adrenals were reported there as 3.2 and 4.8 cm adenomas.

My question is, is it more than likely these are metastasis? Especially given the CT performed over a year ago showed them too? Wouldn’t they have grown considerably more, if they were? One oncologist advised starting chemo, indicating the lower attenuation areas were probably necrotic zones, but we will consult another one to get a second opinion.

I would appreciate any thoughts on the matter. Thank you once again.

March 19, 2016 at 7:19 am  #1273327    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

Welcome to GRACE. Of course, your dad’s own doctors, with access to all the scan images and his other medical records, are in the best position to make a recommendation, but it certainly seems to be a positive factor that these masses have not grown in over a year. Any time you watch a nodule or mass over such a period of time, you expect that if it’s cancer it will show easily measurable growth over that interval. On the other hand, I think it’s a great idea to get a second opinion. An oncologist at a cancer center affiliated with a medical school would be preferred.

Of course the safest route (from the viewpoint of eliminating all possible cancer cells) might be to get chemo and see if the masses reduce in size, but chemo is not without risks.

I hope you have a helpful consultation with the second oncologist.

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 21, 2016 at 12:34 pm  #1273355    

volume

Thank you for your quick response JimC!

We consulted another oncologist today and his opinion is that there is no reason to be concerned. According to the scan the lungs were completely clear and the adrenals showed nothing particularly worrisome. He referred to the tumors as adenomas, and recommended we consult a nephrologist. Still, he noted that such tumors may very well provide fertile ground for metastasis and therefore we should watch these carefully in subsequent scans.

I am somewhat confused, given that one oncologist was ready to start chemotherapy, and the other said that we had nothing to worry about.

It seems the nephrologist will have the final word.

I still think starting chemo just to be safe seems somewhat extreme in this case. Or it doesn’t?

March 23, 2016 at 1:47 pm  #1273368    
catdander forum moderator
catdander forum moderator

Hi Volume,

It’s difficult to say without knowing the patient in detail. This is a link to a discussion that can give you a good idea how specialists think through individual situations. http://cancergrace.org/lung/2010/06/18/adjuvant-chemo-stage-ib-nsclc-case-disc-w-nasser-hanna/

I hope this helps. I know how difficult to be in the position to want THE best for my husband with nsclc but no specific answers.

All best,
Janine

March 24, 2016 at 4:58 am  #1273375    

volume

Thank you catdander!

Unfortunately since my last post, consultations with various specialists have confirmed adrenal metastasis. What is far worse is that even the initial CT done prior to the operation shows a suspicious region within the adenoma, which the radiologist failed to report.
Ultrasound has also confirmed a more accurate size of 5.7 cm and 4.3 cm of the adrenal tumors and we will be starting chemotherapy.

Thank you JimC and catdander for taking the time to respond. I will probably be back to share my dad’s story, so that those who find themselves in a similar position would know what to expect. And of course to bother you with more stupid questions.

Keep up the good work, and stay strong!

March 24, 2016 at 7:31 am  #1273382    
JimC Forum Moderator
JimC Forum Moderator

volume,

Good luck to your dad and to you, and please don’t consider any question “stupid”. We all start somewhere in our quest for knowledge about this awful disease, and we only learn by asking questions.

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 27, 2016 at 12:24 pm  #1273408    

Dr. Ben Creelan

I’m sorry, based upon your description, it seems like he had a rather incomplete work-up and irregular treatment course.

It sounds like it would be prudent to perform a biopsy to determine whether the adrenal lesions are metastatic, and to perform a PET/CT to identify other potential areas of metastasis. As oncologists, we also routinely do a MRI or CT of brain to rule out metastasis there too. The treatment choice depends on the extent of the cancer. Hope this helps.

April 1, 2016 at 2:58 am  #1273486    

volume

Thank you for your response Dr. Ben Creelan.

Indeed the work-up and the treatment have been unsatisfactory to say the least. But I believe we are finally on the right track. Next week my dad is starting chemotherapy (still don’t know the meds). A surgeon we consulted is strongly convinced that the lesions in the adrenals are metastasis and recommended we do several cycles of chemo, and then perform a PET/CT to see if the tumors are under control and MAYBE consider surgery (with numerous IFs as he put it). The oncologist also believes there is no real reason to perform any more scans now, and instead we should do a more complete restaging after 4 cycles of chemo.

I find it peculiar also that my dad’s CEA levels are quite normal (1.75 with a reference value of 5) despite scans showing an active growing tumor in the adrenals. Another concern we have is the slight anemia my father has. The oncologist mentioned it but did not seem too concerned. Wouldn’t anemia be an issue with chemo?

April 1, 2016 at 2:53 pm  #1273493    
catdander forum moderator
catdander forum moderator

CEA levels aren’t a good or consistent method of determining nsclc activity. Anemia is an unfortunate side effect from chemo and slightly lowered levels are common in chemo used for nsclc but usually aren’t cause for stopping or waiting to treat.

All best,
Janine

April 6, 2016 at 8:49 am  #1273528    

volume

I am back with more questions :)

My dad just had his first chemotherapy treatment today. What I got from the oncologists is that they are doing Carboplatin + Paclitaxel once every 3 weeks. Tomorrow he is getting a shot of “something to boost his leukocytes” – as retold by my father, since I was not there when he spoke about this with the oncologist.

What worries me is that 2 of the oncologists at the hospital where he is being treated insisted that this drug combination would not require any anti-nausea medications. They warned us mostly about flu-like muscle and joint pains. Adding he might get diarrhea.

Is it possible to go through chemotherapy without any anti-nausea medications? I asked explicitly twice, if we should get any Zofran or something of the sort. And I was told it wouldn’t be necessary.

I have read that Carbo is less toxic than Cisplatin, but still.. no anti-nausea stuff?

Also would a 4 cycle plan be sufficient to see if this combination is having an effect?

April 6, 2016 at 9:58 am  #1273530    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

Each of these drugs can cause nausea and vomiting, so I’m not sure why you’re not being prescribed something for that possibility, unless there is some medical reason to avoid an anti-nausea medication. Usually nausea is best prevented rather than treated (it’s tougher to get rid of once it appears). If you can’t get your doctors to prescribe it now, then I would say that you should ask again at the first sign of nausea.

If it helps, here are reference pages from Drugs.com on these drugs:

http://www.drugs.com/sfx/carboplatin-side-effects.html

http://www.drugs.com/sfx/paclitaxel-side-effects.html

Also, four cycles is pretty typical. There tends to be much less response after the first four cycles, and very little reason to go beyond six cycles.

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

April 7, 2016 at 9:19 am  #1273535    

volume

Thank you JimC!

After reading through the information on the drugs I did ask once again about anti-nausea medication and finally we got a prescription but we were advised to only use it at the first sign of nausea.

He was also prescribed folic acid. Does this seem reasonable as a supplement?

So far my father has had no side effects from the chemotherapy, and it has already been more than 24 hours since the infusion. Is it possible for side effects to kick in later than this?

April 7, 2016 at 2:42 pm  #1273540    
catdander forum moderator
catdander forum moderator

Hi volume,

It’s good to hear your dad isn’t having side effects. It’s very possible that the reason he not having side effects is the meds given with chemo usually include anti nausea meds and steroids. These meds usually help the person feel alright (sometimes really good) for the first 24 hours post infusion. However as the IV drugs wear off fatigue and nausea often set in and last 2 or 3 days. This is why you really want him to be on top of the anti nausea meds and be prepared for fairly extreme fatigue. Also subsequent infusions tend to become progressively more difficult. With luck your dad will be one of the lucky people who flies through chemo without much difficulty.

It’s not unusual for those receiving chemo to take folic acid. From the website livingstrong, “Folic acid, also called folate and vitamin B9, is a vitamin essential to red blood cell production. Many people receiving chemotherapy for cancer experience drops in their folic acid levels and blood counts due to the effect of certain drugs. A low red blood cell count indicates anemia, a condition of reduced oxygen distribution throughout the body from the lower circulation of blood cells. Anemia can be caused by deficiencies in folic acid, several other B vitamins, iron and even protein. “ http://www.livestrong.com/article/538148-folic-acid-chemotherapy/

All best to you and your dad,
Janine

April 7, 2016 at 3:11 pm  #1273541    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

I’m glad your father has a prescription for anti-nausea meds. Although I hope he doesn’t need them, at least it’s there to be used if nausea sets in. It commonly takes two or three days for nausea to set in, so it still could arise. If it does, he should take the medication as soon as possible and note the interval between the infusion and the first signs of nausea. Then next cycle, start taking the anti-nausea meds an hour or two sooner, in an attempt to head off nausea before it becomes an issue. It also helps to eat smaller, more frequent meals rather than large meals. Bland food tends to be tolerated better, and a few crackers or something similar when symptoms begin may help prevent it from worsening. My wife’s chemo nurse suggested taking a walk in the fresh air, and that seemed to work well to stave off nausea.

Folic acid (folate) is usually prescribed along with Almita in an effort to minimize side effects, but I’m not familiar with its use with carbo/taxol. As Dr. West has stated:

“I don’t recommend folate supplementation outside of giving it with Alimta, but I don’t have a problem with a low daily dose if people are inclined to take it. I’m not aware of any clinical evidence that it significantly worsens cancer outcomes in any setting.” – http://cancergrace.org/forums/index.php?topic=10107.msg80572#msg80572

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

June 16, 2016 at 2:47 am  #1274382    

volume

Hi, everyone! I hope you are all doing well. I am back with an update and some more questions.

My dad completed his 4th cycle of chemo and had a CT. So far he’s been doing relatively well, the only real issue being joint and muscle pain. Doctors want him to do another 2 cycles of carbo/taxol after they reviewed his CT. It showed one of the adrenal lesions had shrunk to 4.4 cm from 4.7, but the other had gone from 3.4 to 5.8!

Is it really possible to have such varying effects? I mean one tumor shrinking, though only a little, while the other growing? What is more that same adrenal tumor was seen on an unrelated CT scan over 1 year ago (before my dad’s cancer was diagnosed) as being 4.8 cm in size? Could this variation in size be due to something other than metastatic disease?

Another question which we are yet to discuss with the oncologists is what’s next? After the 6 cycles I mean. What are the possibilities for my dad with his resected squamous lung cancer and semi-responding adrenal mets? Is it some sort of maintenance? From what I gather, squamous isn’t really a good histology for maintenance. Or is it?

June 16, 2016 at 8:03 am  #1274389    
JimC Forum Moderator
JimC Forum Moderator

Hi volume,

Thanks for the update. It is possible to have what’s called a “mixed response” to treatment, in which some areas of cancer remain stable or shrink, while others grow. It’s hard to say what is going on with the adrenal masses, but it may be a good idea to get a biopsy of those presumed adrenal mets, as Dr. Creelan suggested. They don’t really seem to have been affected by chemo (the change from 4.7 to 4.4 is pretty minimal and could just indicate a difference in the scans or measurement techniques used by the radiologist), so it would be helpful to know for certain whether these really are metastases.

If a decision is made to continue treatment, one of the most promising options is immunotherapy, as discussed here.

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

June 16, 2016 at 8:22 am  #1274390    
catdander forum moderator
catdander forum moderator

Hi volume,

I’m glad your dad has been doing alright.

It’s possible the 4.4/4.7/4.8 mass isn’t cancer. The measurements could be just differences in reading even if it’s the same person. Studies have even shown that to be true. However it is possible to have response in one tumor and not in another.

It’s come to light after several years of maintenance treatments that it works best for those who would otherwise not keep a close eye on the cancer, i.e. scanning every 3 or so months. Most oncology specialists would agree that if progression is caught early then a break between 1st and 2nd line is fine. It’s important to let the oncologist know of new or worsening symptoms and scan regularly. It doesn’t really matter whether it’s squam or adeno though.

I hope you dad does well for a long long time.
All best,
Janine

June 16, 2016 at 1:09 pm  #1274400    

volume

Thank you for your responses JimC, catdander!

Doctors here seem to be reluctant to do a biopsy. I have not mentioned it previously but this is all happening in a land far, far away in Europe, and maybe that is why the way things are done here might seem somewhat odd/different.

We consulted the best surgeon in the country, specializing in adrenal surgery, who stated that he would not perform a biopsy given the evidence (histologically verified primary NSCLC, CT scans, lesion size and growth), and recommended chemotherapy instead.

As for immunotherapy,I know that ramucirumab, pembrolizumab, and nivolumab are available, but I am not sure if our state insurance fund would cover these in my father’s case (given that he is a 72 year old ex-smoker with advanced lung cancer).

Thanks once again for your responses and support!

June 16, 2016 at 2:23 pm  #1274403    

cards7up

Being a LC survivor and having had a recurrence, I would never do any treatment without knowing if it was cancer or not. Not doing a biopsy doesn’t sound reasonable to me unless that’s the way they treat stage IV patients. I would insist on a biopsy of at least one of the adrenal glands. 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

July 11, 2016 at 2:18 pm  #1274643    

volume

cards7up, thank you for your input! As I mentioned, the best specialist around advised against the biopsy and recommended chemotherapy until the tumors are under control and my father becomes eligible for adrenalectomy, Which unfortunately does not seem to be the case so far, since one of the tumors kept growing, while the other shrank insignificantly.

Unfortunately, as of today my father is in hospital due to suspected pneumonia after he suddenly developed fever and chills. His leukocytes dropped from 2.2 in the morning to 1.9 in the afternoon and he was admitted.

This is the pressing issue for the moment, but I still have not given up on his treatment and will continue to pursue all possibilities. I would really appreciate your opinions, as people on this forum know a lot about this dreadful disease and have really helped me in this battle.

So, here I go :)

Given the serious complications arising, would it be too bad if my father skipped the 6th cycle of carbotaxol? I fear it will only be worse after the 6th infusion, while the CT demonstrated a mixed response at best.

I am highly doubtful about the prospects of my father getting approved for immunotherapy treatment, so are there any other options? Would docetaxel be a viable option in his case? Or erlotinib?

Also what about SBRT? Is that an option for threating metastasis to both adrenals?

Than you!

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