Treatment Options

Portal Forums Lung/Thoracic Cancer EGFR Inhibitors Treatment Options

This topic contains 36 replies, has 4 voices, and was last updated by  cc1990 1 month, 2 weeks ago.

Viewing 17 posts - 21 through 37 (of 37 total)
Author Posts   
Author Posts
September 15, 2017 at 11:29 am  #1292403    
JimC Forum Moderator
JimC Forum Moderator

Hi Kate,

Small cell and large cell are part of a continuum of Neuro-endocrine cancers. Dr. West describes that continuum here: http://cancergrace.org/lung/files/2010/01/horton-pt-2-neuroendo-lung-tumors-and-bac-transcript.pdf

Normally the carbo/etoposide regimen is used for 4-6 cycles, then treatment is stopped, depending on the results. In any event, the platinum component is usually not continued.

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

September 15, 2017 at 11:55 am  #1292404    
catdander forum moderator
catdander forum moderator

Dr. West explains large cell and small cell neuroendocrine lung cancers, “One of the less common subtypes of non-small cell lung cancer is known as large cell neuroendocrine, and it is in the same family as small cell lung cancer — these are all known as neuroendocrine cancers. They originate from cells that are in the middle of the body, in the middle of the chest, that have evolved to have hormone-secreting abilities. Because of that, large cell neuroendocrine and small cell lung cancer really share enough features that they are treated in a very similar way.” Dr. West goes on to discuss how these 2 lung cancers are treated similarly. http://cancergrace.org/lung/2016/04/19/gcvl_lu_histology_specific_recommendations_large-cell_neuroendocrine/

September 15, 2017 at 12:09 pm  #1292405    
catdander forum moderator
catdander forum moderator

In the following post Dr West explains why treatment using platinum is only used 4 to 6 treatment.

“With carboplatin, cumulative cytopenias (low blood cell counts) and a rapidly escalating risk of a severe and potentially dangerous hypersensitivity reaction (which can also occur with ongoing cisplatin but is notorious and almost inevitable with carboplatin) make indefinite carboplatin too challenging and inadvisable.” http://cancergrace.org/lung/2011/12/24/beyond-4-cycles-1st-line/

September 15, 2017 at 4:40 pm  #1292408    

cc1990

Thank you, Jim and Cat, for all that information, it’s a lot to digest, but I think of have a clearer picture of what’s going on.

Can you explain 4-6 cycles of the carboplatin/etoposide regimen… does that mean 4 months to 6 months or would this be in weeks, i.e. 4 weeks to 6 weeks and is this for 5 days a week of treatment?

Kate.

September 15, 2017 at 6:30 pm  #1292409    
JimC Forum Moderator
JimC Forum Moderator

Hi Kate,

A “cycle” refers to each treatment and the off-weeks following it. Typical is a three week cycle, in which the chemo infusion is given on day one, with the next one three weeks later. That allows time for blood counts to recover and side effects to fade.

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

September 15, 2017 at 10:59 pm  #1292410    
catdander forum moderator
catdander forum moderator

If taking one chemo drug the infusion would be once a cycle. For a platinum doublet like carbo/etoposide a cycle usually consist of 3 infusions in week one for a 3 week cycle or even 1 infusion a week for 3 weeks in a 4 week cycle. An example from the macmillan is below. Note that this is from a UK site and I don’t think capsules are used much or at all in the U.S. Otherwise this is a pretty typical schedule.

“Your course of carboplatin and etoposide
You have chemotherapy as a course of several sessions (or cycles) of treatment over a few months. Carboplatin and etoposide chemotherapy can be given in different ways. Your doctor or nurse will be able to give you details of your individual treatment course.

Here is a description of one method of treatment:

Each cycle of carboplatin and etoposide takes 21 days (three weeks).

On day 1 you have carboplatin and etoposide. Both drugs are given as a drip.
On day 2 you will have either an infusion of etoposide or you will be given
etoposide capsules.
On day 3 you have an etoposide drip or capsules. The capsules are taken twice a day.” http://www.macmillan.org.uk/cancerinformation/cancertreatment/treatmenttypes/chemotherapy/combinationregimen/carboplatinetoposide.aspx

September 16, 2017 at 11:00 am  #1292412    

cc1990

Thank you both for your quick responses!

Given that my husband is EGFR+, but has large cell/small cell mix with neuro-endocrine features which a tissue biopsy was taken from a lymph node:

1) does this mean that it’s just in that lymph node and the goal of the chemo is to wipe-out the small cell or does he have small cell throughout his body??? Would there be any radiation involved like SBRT?

2) also noted was “aorticopulmonary window lymph node” measuring 13 x 12 mm. What is that? Is that near his heart?

3) if we wanted to look for clinical trials would we look for SCLC trials?

Kate

September 16, 2017 at 11:42 am  #1292413    
JimC Forum Moderator
JimC Forum Moderator

Hi Kate,

A biopsy is a snapshot of the cancer in the area that has been sampled, and may or may not be representative of the cancer in the rest of the body. Carbo/etoposide is a regimen that is effective in both NSCLC and small/large cell lung cancer, so you would hope to be treating the cancer throughout the body. Usually, in the stage IV setting radiation is not used except to reduce symptoms (such as pain from bone mets) and for brain mets. Exceptions may be made in instances where there is only one or two areas of metastasis.

“The AP window is the space between where the aorta turns around and the pulmonary artery. There are lymph nodes here that can be involved in lung cancer or lymphoma.”http://cancergrace.org/forums/index.php?topic=4942.msg30180#msg30180

You would probably look for SCLC trials, then check to see if this particular combination qualifies for entry.

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

September 19, 2017 at 6:50 pm  #1292760    

jeanned

As a new member, I am amazed what I have already! Thank you!

My husband was diagnosed in November 2014 with Stage 4 NSCLC . He has had numerous treatments in the past two and a half years. He has been on Tagrisso with some progression so in June, his oncologist added Avastin every three weeks. He has increasing bone metastasis and severe pain. The oncologist has now added Alimta to the mix, also every third week. He has only had one dose of the Alimta and is having severe undesirable side effects.

Has anyone taken this combination of drugs?

Thank you,
Jeanned

September 19, 2017 at 7:13 pm  #1292767    
JimC Forum Moderator
JimC Forum Moderator

Hi jeanned,

Welcome to GRACE. I’m sorry to hear of your husband’s progression and symptoms. I’m sure that other oncologists have experimented with similar combinations, but at this point there isn’t strong evidence of its efficacy. That’s not to say it’s a bad choice; all three drugs are approved for and show activity in lung cancer.

When side effects of treatment become burdensome, oncologists often consider dose reductions and/or discontinuing one or more drugs in a combination. If progression under Tagrisso was significant, that might be stopped or the dose reduced. If not, Avastin might be the one which is contributing the least.

Also, your husband’s doctor could evaluate his side effects to see if it can be determined which drug is most contributing to those toxicities.

Finally, pain from bone mets can often be reduced with focal radiation to those metastases.

I hope your husband can find relief from his symptoms/side effects, and settle in on a treatment that effectively controls his cancer.

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

September 20, 2017 at 5:50 pm  #1293004    

cc1990

Has anyone ever heard of transformation from NSCL to SCLC and then change again?

Kate

September 20, 2017 at 7:15 pm  #1293084    
JimC Forum Moderator
JimC Forum Moderator

Hi Kate,

I have not heard of that phenomena, but if a biopsy result suggested it, I would tend to think it might represent NSCLC cells that had not transformed into SCLC originally. Often a cancer is not homogeneous, especially when changes occur over time. As an example, an EGFR+ patient may develop T790M resistance, but that doesn’t mean that all the cancer cells will bear that new mutation.

All that being said, the mantra is that cancer seems to be capable of anything.

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

October 6, 2017 at 10:07 am  #1293253    

cc1990

Since my husband morphed to SCLC, he had his first treatment of etoposide on September 20th, 21st and 22nd. He continues on the Tagrisso @ 40 mg daily and she is being very cautious as she does not want a major flare-up if she were to stop it immediately. Also, he has had problems in the past with low platelets. So overall taking baby steps in his treatment. She said after etoposide next week she will order scans to see his response and then will decide on whether to add carboplatin, drop Tagrisso, etc.

BTW: he feels fairly well. He has pain in his back, rib area and a feeling of chest pressure, but that is managed by meds, Fatigue is the main problem and weight loss, but he was put on Megace to help with his appetite.

Has any one had good response/success just on the etoposide?

Kate

October 6, 2017 at 11:53 am  #1293255    
catdander forum moderator
catdander forum moderator

Hi Kate,

Etoposide is a fairly old drug researched as a doublet companion to a platinum drug. At that time treatment didn’t normally go past the initial first line. So like most of the chemo drugs developed at that time research as a single agent is pretty scarce but oncologists do commonly use it with success for second line treatment or for those who are frail and can’t handle platinum drugs. There is one study I found after a quick search that tests oral etoposide. https://www.ncbi.nlm.nih.gov/pubmed/2154860

All best,
Janine

October 22, 2017 at 12:01 pm  #1293376    

cc1990

I have another question, and thank you Janine for the one study that you sent me. When I asked the oncologist about the oral form of Etoposide she seemed to have blew me off… maybe they don’t use it that often now.

Given my husband was diagnosed with EGFR L858R (exon 21) in 2013 and since now he has small cell. Does this mean he does not have the EGFR, L858R (exon21) anymore?. See below from surgical pathology report:.

1. Right mainstem endobronchial tumor, biopsy:
– Combined small cell and large cell neuroendocrine carcinoma. See note.
Note: Immunohistochemistry shows that the tumor cells are positive for synaptophysin (diffuse), CD56 (diffuse), chromogranin (focal), while negative for TTF-1. Ki-67 proliferative index is approximately 90%. Tumor cells show the loss of RB expression. Given the known history of recurrent EGFR-mutated lung adenocarcinoma, the findings could represent the phenomenon of small cell/large cell neuroendocrine transformation of the underlying EGFR-mutated lung adenocarcinoma; however, molecular confirmation is recommended. Prior lung biopsy (S17-52131) was reviewed, and confirmed to show conventional acinar lung adenocarcinoma.

We hear a lot of people saying that since he is small cell now there should be a lot of treatment options, but then the oncologist is saying no, due to having a mixture.

What’s your opinion on this?

Kate

October 22, 2017 at 3:35 pm  #1293378    
JimC Forum Moderator
JimC Forum Moderator

Hi Kate,

As we discussed earlier in this thread, lung cancer is often not completely homogeneous-there can be cancer cells of differing pathologies in the same patient. The sample which was tested may indicate small cell/large cell, but there may still be cancer cells in other locations that remain NSCLC and EGFR+. On the other hand those cells that have tested as small cell/large cell may have mutated from EGFR+ NSCLC, which explains the radiologist’s recommendation for molecular testing.

Although mixed SCLC/NSCLC is not that uncommon, since the proportions and amount of spread of the components tends to dictate the treatment used, there don’t tend to be treatments specifically geared toward mixed SCLC. Often a treatment is chosen which tends to be effective against both. Dr. Pennell discusses treatment choices in this thread, and you can access a discussion of immunotherapy for SCLC patients 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

October 23, 2017 at 6:29 am  #1293380    

cc1990

Thank you, Jim, and thank you for the threads!

Kate

Viewing 17 posts - 21 through 37 (of 37 total)

You must be logged in to reply to this topic.