Non smoker with mucinous BAC - 1255065

Chelle,

Unfortunately, the "pneumonic" form of BAC is named that because it looks for all the world like pneumonia, and just about everyone is treated for presumed pneumonia for at least weeks and often months before the diagnosis is made that it is BAC and not pneumonia.

If the cancer is all completely contained within one lobe, we most often favor doing the surgery even knowing that the cancer is high risk for recurring elsewhere in the lungs, often within months after the surgery. Still, that's not always the case, and if the cancer has been followed for a year now before the diagnosis was made, and the cancer hasn't spread elsewhere in that time, it suggests that surgery could still be of benefit.

In addition, many people with a pneumonic mucinous BAC are bothered by severe shortness of breath and/or a productive cough that can be relieved with surgery. We generally don't do a lobectomy as a "palliative" (non-curative) treatment if we know or suspect there is cancer elsewhere, but one exception we sometimes make is for pneumonic BAC, since that part of the lung isn't functioning the way it's supposed to, but it's having blood run through it, effectively mixing the unoxygenated blood from the BAC-affected lung with the oxygenated blood from the rest of the lung. So keeping the lung in can actually lead to worse lung function than removing it because of a so-called "shunting" effect.

As I indicated above, I'd still consider surgery to be a realistic option if there isn't evidence that the cancer is in other lobes, and if symptoms are significant enough, perhaps even if it is.

Aside from chemotherapy, which can sometimes be effective, I've seen some patients with pneumonic/mucinous BAC who have an ALK rearrangement in their tumor, so that's worth checking for. If present, that's associated with a high chance of response to oral XALKORI (crizotinib).

-Dr. West

PS: there's a ton of info about BAC on this site, more than I can summarize here.

The consolidated part of the lung probably isn't functioning, but in the best case scenario, if it responds well to treatment, it could regain function. If a treatment is working, whether it's a targeted therapy or chemo, it will probably also help with the fluid collection and cough.

ALK rearrangements aren't common in lung cancer: they are seen in about 4% of people with advanced non-small cell lung cancer (NSCLC), but they're more common in never-smokers, where the probability is more like 10-15%. A core biopsy is usually enough to do testing from -- it's not necessary to do a bigger surgery for the vast majority of cases.

-Dr. West

I'm glad he has an EGFR mutation, which suggests he has a high probability of responding well to an EGFR inhibitor like Tarceva, but no, these agents don't cure BAC. They can lead to a dramatic response, even one so good that you can't see any evidence of the cancer, but it is pretty close to inevitable that the cancer will return if the cancer has spread outside of a single lobe.

I think the best we can say about an EGFR mutation and ALK rearrangement co-existing is that it's possible, though it's extremely unlikely. Almost all experts would consider it not indicated to do testing for an ALK rearrangement at this point, if an EGFR mutation has been seen. I don't think it's really an appropriate test to do, if the best we can say is that it's not impossible to have an ALK rearrangement. The presence of an EGFR mutation clearly guides the decision of the best systemic treatment to pursue.

I can't answer your last question. It's too specific for me to make a recommendation based on such a limited amount of information, and it pretty clearly veers into the range of giving a very specific medical recommendation on a specific case of someone who isn't my patient.

-Dr. West