Single prevascular node enlargement: localized radiation or surgical removal?

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This topic contains 7 replies, has 4 voices, and was last updated by  My wife’s advocate 8 hours, 37 minutes ago.

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August 1, 2017 at 8:38 am  #1291163    

My wife’s advocate

After a prolong 6 1/2 years stage IV battle for survivor on Tarceva, my wife’s last four CAT scans(in a period of one year) have shown a rapid increase in size of a solitary prevascular lympth node from 1cm to 2.6×3.2 cm. She is still asymtomatic but with a very mild cough and “frog in her throat” once or twice a day when she lay flat in bed.

CAT guided needle biopsy was aborted due to risk of major bleeding from artery by sternum area. Serum biopsy shown negative T790M. She has no cancer load anywhere else other than this new enlarged solitary node. However, she have had two prior brain surgeries to remove solitary brain met and necrosis on the same site within her right occipital lobe area. Most recent two brain MRI were clear of any sign of cancer.

What would be a reasonable choice? Localized radiation or out right excisional biopsy to remove the one and only enlarged node? Any targeted therapy for non-T790M suspected acquired resistance candidate?


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

August 1, 2017 at 10:54 am  #1291168    
catdander forum moderator
catdander forum moderator

Hi Advocate,

The leading course today would be to eliminate the one area of growth. The thinking is if this is the only area of progression it is probably the only area of resistance, leaving all else under the thumb of tarceva. Whether radiation or excision is up to the team involved to determine what is safest in your wife’s case. If it’s radiated you’ll not have to chance to check for t790m but if it is taken out you’ll have the whole nodule to test, which is a good thing since t790m can be found in one part of a nodule but not in tissue in the same nodule.

Keep us posted
Hoping for the best,
Janine

August 1, 2017 at 4:37 pm  #1291174    

My wife’s advocate

How large of an acquired resistance mutation cell load does one required to have before a serum biopsy could be considered as reliable as the actual tissue biopsy?


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

August 1, 2017 at 10:49 pm  #1291175    
catdander forum moderator
catdander forum moderator

I’m not sure of the answer so will ask one of our oncologists or Jim to comment.

August 2, 2017 at 8:48 pm  #1291182    
Dr West
Dr West

There isn’t any specific number or tumor size. In general, the more cancer visible on a patient’s scans, the better the chance of a plasma (blood-based) test being able to detect sufficient circulating tumor DNA to have the test detect mutations that are actually present in the tumor. Lung cancer that is only seen in the chest has a lower success rate for detecting mutations on the blood test (about 50-60% success rate) than cancers that have spread outside of the chest (about 70-80% success rate in trials).

Good luck.
-Dr. West

August 15, 2017 at 9:31 am  #1291248    

My wife’s advocate

Thank you again Dr. West for responding.

Is it true that an enlarged lymph node can never be fully excised because it is usually attached to or entangled with all kinds of blood vessels?

My thinking is since the thoracic surgeon is going through all the trouble (cutting a rib, deflating the lung..etc, just to get to the mediastinum area) for the biopsy, why not completely remove the suspected cancerous node?

She is now experiencing more frequent coughing spells possibly due to the enlarged lymph pressing on a nerve somewhere.


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

  • This reply was modified 1 week ago by  My wife’s advocate. Reason: adding a symptom as part of the question
  • This reply was modified 1 week ago by  My wife's advocate. Reason: adding a symptom as part of the question
August 16, 2017 at 6:08 am  #1291254    
JimC Forum Moderator
JimC Forum Moderator

Hi,

Enlarged lymph nodes can at times be resected, in a procedure known as lymphadenectomy, but as with any surgical procedure, the particular circumstances may dictate whether the procedure can be performed on a specific lymph node, and what risks may be involved. With that in mind, a conversation with the surgeon would be in order to discuss the advantages and disadvantages of resection in your case.

Good luck,

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

August 22, 2017 at 6:36 pm  #1291296    

My wife’s advocate

Thank you JimC for your attempt to explain and answer my question.

The docs now decided to schedule a mediastinotomy on the pre-vascular lymph node. They are still set to get to the bottom of the suspected “acquired resistance” to Tarceva.

Been reading a bit on the procedure. Very concern on the risk. The surgeon already mentioned that she has to cut a small section (about 1 inch) of my wife’s rib bone in order to get to the spot where the enlarged lymph node is located, to get a good sample.

Fortunately and unfortunately that is the only point of cancer load or resistance, so there is no other place they can get to the cancer.

Just wondering if this is worth the risk as opposed to just go for chemo?


Wife, Asian non-smoker, 10/2010 left upper lobectomy, Diag: mod. diff. adenocarcinoma, focal squamous diff. with one AP node involvement. Dec 2010 thru Mar 2011 4 cycle cisplatin/vanorabin doublets completed. July 2011 MRI shown one 1.3 cm lesion with a 2.6 cm cystic component in rt. occipital region. Aug 2011 Neuro excision, confirmed sol. met from lung. Tested EGFR +. SRS irradiation on excision site 9/9/11, started Tarceva 9/26/11. Very difficult side effects. Tolerable after dose reduction to 100mg. Dec 2015 second brain surgery found life cancer cells in large bed of necrotic tissue. Feb-Mar 2016, 12 fractionized IMRT on right occipital lobe. Remain on Tarceva. Aug 2016 to Jun 2017 enlargement of pre-vascular lymph node from 1.4 to 2.2 cm. Mediastinotomy scheduled Sept 2017.

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